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RECAP 


The  Distribution  of  Adenomyomas 
Containing  Uterine  Mucosa 


By 

THOMAS  S.  CULLEN,  M.  B. 

Baltimore 


PROPERTY  OF 

COLUMBIA  University 

Geo.  Crocker  Special  Research  Fund 


Columbia  SSnitier^itp 

mt^eCttpoflrtngork 

CoHtge  of  ^fjpgitians!  anb  ^urgeong 
Hibrarp 


THE   DISTRIBUTION   OF   ADENOMYOMAS 
CONTAINING  UTERINE  MUCOSA 


BY 


Thomas  S.  Cullen 

Professor  of  Clinical  Gynecology  in  the  Johns  Hopkins  University  and  Visiting 
Gynecologist  to  the  Johns  Hopkins  Hospital 


Reprinted   from    the   Archives    of   Surgery 
September,  1920,   Vol.  I,  pp.  215-283 


Copyright,    1920 

American   Medical  Association   Press 

Five    Hundred    and    Thirty-Five    North    Dearborn    Street 

CHICAGO 


PREFACE 


This  paper  was  the  address  in  Surgery  before  the 
Western  Surgical  Association  in  Kansas  City,  Decem- 
ber. 1919. 

I  have  had  it  reprinted  in  order  that  my  friends  may 
have  it  in  separate  form. 

I  wish  to  express  my  indebtedness  to  Mr.  Max 
Brodel,  Director  of  the  Department  of  Art  in  Medicine, 
for  the  excellent  illustrations. 

Oct.  1,  1920.  Thomas  S.  Cullen. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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http://www.archive.org/details/distributionofadOOcull 


THE    DISTRIBUTION    OF    ADENOMYOMAS    CONTAINING 
UTERINE    MUCOSA* 


THOMAS     S.    CULLEN,    M.B. 

BALTIMORE 


At  a  meeting  of  the  Johns  Hopkins  Hospital  Medical  Society  in 
March,  1895,  I  reported  my  first  case  of  adenomyoma  of  the  uterus, 
and  since  then  I  have  been  on  the  lookout  for  tumors  of  this 
character.  From  time  to  time  the  results  of  my  labors  have  been 
recorded  either  in  book  form  or  in  the  literature. 

I  have  been  amazed  at  the  widespread  distribution  of  these  tumors 
consisting  of  nonstriped  muscle  with  islands  of  uterine  mucosa  scat- 
tered throughout  them.  In  May,  1919,  I  read  a  short  paper  on  the 
subject  before  the  New  York  State  Medical  Society  at  Syracuse.  This 
fragmentary  article  was  published  ^  a  few  months  later. 

In  the  present  paper  I  shall  not  attempt  to  cover  the  literature  on 
the  subject,  but  I  shall  confine  my  remarks  to  a  description  of  the 
cases  and  of  the  pathologic  material  that  I  have  personally  observed 
since  reporting  my  previous  cases. 

Thus  far  I  have  found  uterine  mucosa  in  ten  places  in  the  body 
as  indicated  in  Figure  1,  and  I  shall  therefore  discuss  the  subject 
under  the  following  heads  : 

1.  Adenomyoma  of  the  body  of  the  uterus. 

2.  Adenomyoma  of  the  rectovaginal  septum. 

3.  Adenomyoma  of  the  uterine  horn,  or  of  the  fallopian  tube. 

4.  Adenomyoma  of  the  round  ligament. 

5.  Uterine  mucosa  in  the  ovary. 

6.  Adenomyoma  of  the  utero-ovarian  ligament. 

7.  Adenomyoma  of  the  uterosacral  ligament. 

8.  Adenomyoma  of  the  sigmoid  flexure. 

9.  Adenomyoma  of  the  rectus  muscle. 
10.  Adenomyoma  of  the  umbilicus. 


*  Address  in  surgery  delivered  before  the  Western  Surgical  Association  in 
Kansas  City,  December,  1919. 

*From  the  Gynecologic  Department  of  the  Johns  Hopkins  University  and 
of  the  Johns  Hopkins  Hospital. 

1.  Cullen,  T.  S.:  The  Distribution  of  Adenomyomata  Containing  Uterine 
Mucosa,  Am.  J.  Obst.  80:130   (Aug.)    1919. 


ADENOMYOMA    OF    THE    BODY    OF    THE    UTERUS 

These  tumors  may  be  limited  to  the  anterior  or  posterior  walls  of 
the  uterus,  or  they  may  form  a  mantle  or  zone  just  outside  the  uterine 
mucosa.  When  the  uterus  is  cut  open,  it  is  noted  that  the  anterior  or 
posterior  wall,  or  both,  are  thickened.  This  increase  is  due  to  a 
coarsely  striated  condition  of  the  muscle  directly  beneath  the  uterine 
mucosa.  Where  the  uterine  walls  are  especially  thick,  the  diffuse 
myomatous  growth  may  be  several  centimeters  in  thickness.  Scattered 
throughout  the  diffuse  growth,  one  often  notes  small  cystlike  spaces 
filled  with  chocolate-colored  contents,  and  not  infrequently  with  a 
loupe  one  can  detect  here  and  there  uterine  mucosa  penetrating  into 
the  diffuse  growth. 

Occasionally  a  cystlike  space,  1  cm.  or  more  in  diameter,  may  be 
found  in  the  thickened  uterine  wall.  Such  a  space  will  usually  be 
lined  with  a  velvety  membrane  about  1  mm.  thick,  and  the  cavity  will 
be  filled  with  the  characteristic  chocolate-colored  contents  —  old 
menstrual  blood. 

The  line  of  demarcation  between  the  normal  outer  uterine  mus- 
cular wall  and  the  diffuse  myomatous  growth  just  beneath  the  mucosa 
is  invariably  sharply  defined,  but  the  two  are  nevertheless  so  closely 
blended  that  it  would  be  absolutely  impossible  to  separate  them.  Occa- 
sionally such  a  uterus  will  contain  one  or  more  small  discrete  myomas. 
The  histologic  picture  in  a  typical  case  is  very  characteristic :  The 
uterine  mucosa  is  often  of  normal  thickness  and  looks  perfectly  natural, 
but  as  we  approach  the  underlying  diffuse  myomatous  tissue  the 
mucosa  is  seen  to  penetrate  it  in  all  directions,  sometimes  as  an  indi- 
vidual gland;  but  often  large  areas  of  mucosa  are  seen  extending 
into  the  depth.  In  favorable  sections,  one  can  follow  a  prolongation 
of  the  mucosa  half  way  through  the  uterus.  Where  the  diffuse 
myomatous  growth  ends,  the  outward  extension  of  the  glands  also  ends. 
In  the  course  of  time,  portions  of  the  diffuse  adenomyoma  may 
project  into  the  uterine  cavity  and  be  expelled  through  the  cervix  as 
submucous  adenomyomas.  In  other  instances  a  portion  of  the  growth 
is  forced  to  the  outer  or  peritoneal  surface  forming  a  subperitoneal 
adenomyoma.  Such  a  myoma  is  prone  to  become  cystic,  and  the  cyst 
cavity  or  cavities  will  be  filled  with  chocolate-colored  contents. 

Symptomatology. — It  is  not  difficult  to  figure  out  to  what  symptoms 
an  adenomyoma  of  the  uterus  will  usually  give  rise.  In  the  first  place, 
the  mucosa  lining  the  uterine  cavity  is  perfectly  normal,  hence,  as  a 
rule,  we  shall  have  no  intermenstrual  discharge.  With  the  advent  of 
the  menstrual  period,  however,  the  patient  will  not  only  lose  her 
normal  quota  of  blood,  but  this  will  be  greatly  increased  by  the  flow 
coming  from  the  large  areas  of  mucosa  which  are  scattered  through- 
out the  diffuse  myomatous  growth. 


There  will,  as  a  rule,  be  a  great  deal  of  pain  in  the  uterus  at  the 
period  due  primarily  to  the  swelling  of  the  mucosa  which  is  scattered 
throughout  the  uterine  walls.  The  small  and  medium-sized  cystic 
spaces  filled  with  chocolate-colored  fluid  are  due  to  the  accumulation  of 
old  menstrual  blood  in  areas  where  the  continuity  of  the  mucosa  with 
the  uterine  cavity  has  been  interrupted.  Such  areas  also  undoubtedly 
add  to  the  feeling  of  distention  and  discomfort  at  the  period. 


Fig.  1. — The  various  points  at  which  I  have  found  uterine  mucosa:  1,  in  adenomyoma 
of  the  body  of  the  uterus;  2,  in  adenomyoma  of  the  rectovaginal  septum;  3,  in  adenomyoma 
of  the  uterine  horn  or  fallopian  tube;  4,  in  adenomyoma  of  the  round  ligament;  5,  in  the 
hilum  of  the  ovary  usually  unaccompanied  by  a  myomatous  growth;  6,  in  the  utero-ovanan 
ligament;  7,  in  the  uterosacral  ligament;  8,  in  the  sigmoid  flexure;  9,  in  the  rectus  muscle; 
10,  in  adenomyoma  of  the  umbilicus. 

On  bimanual  examination,  the  uterus  is  found  to  be  normal  in 
size  and  perfectly  smooth,  or,  on  the  other  hand,  it  may  be  two  or 
three  times  its  normal  size  and  slightly  nodular.  The  introduction  of 
a  uterine  sound  usually  reveals  a  normal  cavity,  and  on  curettage 
normal  mucosa  is  invariably  found.  From  the  chnical  findings  one 
can  often  make  a  fairly  accurate  diagnosis  of  adenomyoma. 


Generally  speaking,  removal  of  such  a  uterus  is  clearly  indicated. 
Frequently  this  proves  rather  difficult  on  account  of  the  tendency  for 
such  an  organ  to  become  densely  adherent  to  surrounding  structures. 

I  have  discussed  adenomyomas  of  the  body  of  the  uterus  in  such 
detail  elsewhere  ^  that  a  further  consideration  of  the  subject  here 
would  be  superfluous. 

Case  1. — A  bicornate  uterus  zvith  diffuse  adenomyoma  of  the  right  horn. 
Pregn-ancy  in  the  right  fallopian  tube.  Adenomyoma  and  hydrosalpinx  of  the 
left  tube.     Large  cyst  of  the  left  ovary   (Figs.  2,  3,  4,  5  and  6). 

History  (Church  Home  and  Infirmary,  No.  19173). — Mrs.  H.  T.,  aged  36, 
admitted  to  the  Church  Home  and  Infirmary,  May  21,  1918,  and  referred  to 
me  by  Dr.  Marshall  G.  Smith,  complained  of  an  abdominal  tumor,  increasing 
pain  in  the  right  lower  abdomen  and  vaginal  bleeding. 

The  menstrual  periods  as  a  rule  had  been  regular,  lasting  two  days,  and 
she  had  had  pain  in  the  right  lower  abdomen.  Latterly  the  periods  had  been 
irregular.  The  last  normal  period  began  probably  Feb.  25,  1918.  During 
March  and  April,  she  had  had  no  menstrual  period,  but  had  suffered  from  the 
usual  right-sided  pain.  She  again  had  noted  a  flow  on  Maj^  1,  which  had 
lasted  one  daj\  Two  days  had  elapsed  and  then  she  had  had  a  flow  for  seven 
days.  The  patient  had  been  married  twice,  but  had  had  no  children  and  no 
miscarriages. 

On  examination  under  anesthesia,  I  made  out  what  appeared  to  be  a  myo- 
matous uterus  which  extended  well  up  toward  the  umbilicus. 

Operation  and  Result.— Operation  was  performed  May  28.  When  the  abdo- 
men was  opened  we  found  the  tube  on  the  right  side  4  cm.  in  diameter,  and 
adherent  in  the  pelvis.  The  uterus  was  bicornate,  and  the  right  side  was  three 
times  the  natural  size.  The  surface  of  one  of  the  nodules  had  a  brownish 
appearance  suggestive  of  an  adenomyoma.  On  the  left  side  was  an  ovarian 
cyst  which  filled  the  pelvis  and  was  glued  down  by  adhesions.  We  removed 
the  structures  from  left  to  right  and  then  took  out  the  appendix  which  was 
tied  down.  The  abdomen  was  closed  without  drainage.  The  patient  made  a 
good  recovery  and  was  discharged,  June  18. 

Examination  of  Specimen  (Gyn.  Path.  No.  25515). — The  specimen  consists 
of  the  pelvic  structures  intact  (Figs.  2  and  3).  The  uterus  has  been  ampu- 
tated through  the  cervix.  This  portion  consists  of  a  right  and  left  uterine 
horn.  The  right  horn  is  9  cm.  long  and  5.5  cm.  broad.  This  has  two  or 
three  small  bosses  projecting  from  its  surface,  the  largest  being  1.5  cm.  in 
diameter.  The  surface  of  the  last  and  some  of  the  others  and  also  the  adjoin- 
ing peritoneum  has  a  rusty  appearance,  instantl}^  suggesting  adenomyoma.  On 
the  anterior  surface  of  the  uterus  are  a  few  adhesions,  on  the  posterior  surface, 
many  fanlike  adhesions. 

Intimately  blended  with  the  right  enlarged  uterine  horn  is  a  left  uterine 
horn.  The  two  horns  are  separated  from  each  other  by  a  cleft,  about  1.5  cm. 
deep  anteriorly,  but  very  shallow  posteriorly.  The  left  horn  to  the  point  of 
amputation  of  the  cervix  is  7  cm.  long  and  about  3  cm.  broad. 


2.  CuUen,  T.  S. :  Adenomyoma  uteri  diffusum  benignum,  Johns  Hopkins  Hos- 
pital Reports  6:133,  1896;  Adenomyome  des  Uterus,  Berlin,  August  Hirschwald, 
1903;  Adenomyoma  of  the  Uterus,  J.  A.  M.  A.  50:107  (Jan.  11)  1908;  Adeno- 
myoma of  the  Uterus,  Philadelphia,  W.  B.  Saunders  Company,  1908. 


On  section,  it  is  seen  that  both  the  right  and  the  left  horns  have  separate 
cavities.     These  apparently  unite  near  the  external  os. 

The  right  horn  on  section  presents  the  typical  picture  of  adenomyoma 
(Fig.  4).  The  anterior  wall  of  the  right  horn  reaches  a  thickness  of  more 
than  4.5  cm.  There  is  no  vestige  of  normal  muscle  persisting.  The  entire 
wall  of  the  uterus  both  anteriorly  and  posteriorly  shows  the  striated  picture 
characteristic  of  adenomyoma,  and  scattered  everywhere  throughout  both  the 
anterior  and  posterior  walls  are  chocolate-colored  areas  varying  from  1  mm. 
to  5  mm.  in  diameter,  while  small  chocolate-colored  cysts  are  also  found  in 
the  myomatous  nodules  on  the  surface  of  the  uterus. 

The  walls  of  the  left  uterine  horn  present  the  normal  appearance. 

The  right  tube  near  the  uterus  is  about  8  mm.  in  diameter.  As  it  passes 
outward  and  downward,  it  reaches  a  diameter  of  4  cm.  On  section,  it  is  found 
to  be  filled  with  what  looks  like  organized  blood  (Fig.  3). 


Fig.  2  (Case  1). — A  bicornate  uterus  with  adenomyoma  of  the  right  horn;  right  tubal 
pregnancy;  enlarged  left  tube,  the  inner  end  showing  adenomyoma  (Fig.  6),  the  outer  end 
hydrosalpinx;   left  ovarian   cyst.     For  the  finer  details  see   Figure   3. 

The  left  ovary  has  been  transformed  into  a  thin- walled  multilocular  cyst, 
16  cm.  in  diameter.  Its  walls  in  places  are  as  thin  as  parchment.  The  left 
tube  at  the  uterine  cornu  is  fully  1  cm.  in  diameter.  As  it  passes  outward  it 
comes  to  measure  about  2.5  cm.  in  diameter,  and  the  walls  are  very  thin. 

Histologic  Examination. — Right  Uterine  Horn :  Sections  have  been  made 
embracing  the  entire  thickness  of  the  uterus  (Fig.  5).  The  musculature  is 
divided  up  into  diffuse  whorls,  varying  from  5  mm.  to  3  cm.  in  diameter. 
Some  of  these  are  oval  or  circular;  others  are  lonjg  and  run  parallel  to  the 
cavity  of  the  uterus.  Scattered  everywhere  throughout  the  walls  of  the  uterus 
are  dark  areas  containing  minute  cavities  in  their  centers.  Some  of  these 
cavities  have  a  definite  lining  fully  1  mm.  in  thickness.  In  various  places  are 
oval  or  irregular  cystlike  spaces  varying  from  1  to  4  mm.  in  diameter.     The 


majority  of  these  are  partially  filled  with  blood.  Even  with  the  naked  eye 
the  diagnosis  of  diffuse  adenomyoma  occupying  both  the  anterior  posterior 
uterine  walls  is  perfectly  evident. 

With  a  higher  power,  islands  of  normal-appearing  uterine  mucosa  are  seen 
scattered  everywhere  throughout  the  diffusely  thickened  uterine  walls,  and  the 
glands  extend  right  up  to  the  peritoneal  surface.  Even  the  isolated  glands 
are  accompanied  by  the  characteristic  stroma.  In  this  case,  the  muscular  tis- 
sue  immediately  around  the   islands   of  mucosa   is   unusually   dense.     Some  of 


Fig  4  (Case  1).— Adenomyoma  of  the  right  uterine  horn.  This  is  a  longitudmal  section 
through  the  right  horn  of  the  uterus  shown  in  Figure  3.  The  entire  body  of  the  uterus 
shows  a  diffuse  myomatous  thickening,  and  scattered  throughout  the  walls  are  small  cystlike 
spaces.  These  were  in  the  main  filled  with  chocolate-colored  contents.  The  diffuse  adeno- 
myoma extends  right  up  to  the  peritoneal  surface  at  most  points.  At  the  fundus  a  discrete 
myomatous  nodule  can  be  seen.     For  the  low  power  picture  of  the  adenomyoma  see  Figure  5. 

the  blood  at  the  menstrual  period  has  undoubtedly  escaped  to  the  peritoneal 
surface,  thus  accounting  for  the  rusty  appearance  noted  on  the  surface  of  the 
uterus  at  operation. 

This  is  the  most  widespread  adenomyoma  of  the  uterus  that  I  have  ever 
seen.  The  mucosa  lining  the  cavity  of  the  uterus  is  perfectly  normal.  In 
a  few  places,  however,  it  shows  some  tendency  to  extend  into  the  underlying 
muscle. 


8 

Right  Side :  Sections  from  the  blood  clot  in  the  right  tube  show  t^-uantities 
of  placental  villi.  On  some  of  these  both  Langerhans'  layer  and  syncytium  are 
still  visible,  and  one  is  also  able  to  make  out  syncytial  buds.  At  other  points, 
the  villi  have  lost  all  trace  of  epithelium.  No  cellular  structure  is  visible  in 
the  stroma,  and  the  cells  are  recognized  as  mere  shadows.  Their  contours  are 
still  perfectly  preserved.  We  are  dealing  with  a  right-sided  tubal  pregnancy, 
and  as  we  look  back  over  the  history  we  find  that  the  menstrual  cycle  strongly 
indicated  extra-uterine  pregnancy,  but  that  the  relatively  large  size  of  the 
pelvic  masses  completely  overshadowed  the  enlargement  of  the  tube. 

Left  Side :  As  was  noted  macroscopically,  the  left  tube  even  near  the  uterus 
is  unusually  large.  A  section  taken  2  cm.  beyond  the  uterine  horn  is  1  cm. 
in  diameter.  Even  with  the  low  power  it  is  noted  that  it  is  almost  solid 
(Fig.  6).  Its  center  is  occupied  by  diffuse  myomatous  tissue,  and  scattered 
everywhere  throughout  this  are  glands  which  resemble  in  every  particular 
uterine  glands.  The  majority  of  these  lie  in  direct  contact  with  the  muscle, 
but  here  and  there  are  several  glands  embedded  in  the  characteristic  stroma 
of  the  uterine  mucosa.  Some  of  the  glands  are  dilated  and  at  one  or  two 
points  we  can  see  miniature  uterine  cavities.  We  have  in  this  tube  an  adeno- 
myoma  of  the  uterine  type,  and  I  am  totally  at  a  loss  to  e>;plain  its  mode 
of  origin. 

Sections  from  the  large  ovarian  cyst  show  that  the  largest  cavity  is  lined 
with  epithelium  that  is  almost  flat.  In  the  walls  of  this  large  cyst  are  a  few 
glandlike  spaces  lined  with  cuboidal  epithelium.  The  cyst  walls  are  composed 
of  laminated  fibrous  tissue. 

In  this  case,  we  have  a  most  unusual  combination :  a  bicornate  uterus,  the 
right  horn  of  which  presents  a  most  beautiful  example  of  diffuse  adenomyoma ; 
a  right  tubal  pregnancy;  adenomyoma  of  the  inner  end  of  the  left  tube  and 
a  hydrosalpinx  of  its  outer  end,  and  finally,  a  large  multilocular  cyst  of  the 
left  ovary  apparently  of  the  retention  cyst  variety. 

ADENOMYO'iVIA    OF    THE    RECTOVAGINAL    SEPTUM  ^ 

I  wish  to  lay  unusual  emphasis  on  this  group  of  cases.  Many  of 
you  have  undoubtedly  seen  them,  but  may  not  have  recognized  them. 
They  are  of  unusual  importance,  and,  if  overlooked,  will  in  time  cause 
the  patient  to  become  a  chronic  invalid,  and  in  some  instances  will 
undoubtedly  lead  to  her  death. 

In  1913,  Dr.  D.  S.  D.  Jessup  of  New  York,  knowing  my  interest 
in  adenomyomas,  sent  me  specimens  of  two  tumors  of  this  class. 
The  mail  on  the  following  morning  brought  me  the  Proceedings  of  the 
Royal  Medical  and  Chirurgical  Society  of  London,  containing  Cuth- 
bert  Lockyer's  splendid  article  on  "Adenomyoma  of  the  Rectovaginal 
Septum."  These  two  communications  set  me  thinking,  and  I  at  once 
felt  sure  that  two  of  my  cases  undoubtedly  belonged  in  this  category, 


3.  Cullen,  T.  S. :  Adenomyoma  of  the  Rectovaginal  Septum,  T.  A.  M.  A. 
62:835  (March  14)  1914;  Tr.  South.  Surg.  &  Gynec.  A.  26:106,  1913;  A 
Further  Case  of  Adenomyoma  of  the  Rectovaginal  Septum,  Surg.,  Gynec.  & 
Obst.  20:260  (March)  1915;  Adenomyoma  of  the  Rectovaginal  Septum,  Bull. 
Johns  Hopkins  Hosp.  28:343    (Nov.)    1917. 


f 


ts. 


n 


Fig.    3    (Case   1). — Diffuse   adenomyoma   of  the   uterus.     This   is   a  longitudinal  sein 
slit  a,  noted  in  the   lower   and  right   portion   of  the   picture,   represents   the   uterine  c: 
whole   present  the   usual   appearance.      The   posterior  wall   of   the   uterus   is    somewhat 
a   diffuse   myomatous   thickening,    and    where   the   muscle    is    arranged   in    whorls   then 
are  dilated,   forming  round,  oval,  or  irregular  cyst  cavities.     The  glands  extend  righ  n 
adenomyoma  of  the  uterus.  "^ 


7.  : 

da 

to 


,_. a, 

\  through  the  right  horn  of  the  uterus  shown  in  Figures  3  and  4.     The  longitudinal 

J      It  can  be  traced  upward  and  toward  the  left:     The  glands  of  the  mucosa  on  the 

■kened  and  the  anterior  wall  markedly  so.     The  greater  part  of  the  uterus  presents 

nearly  always  a  gland  or  a  colony  of  glands  in  its  center.     Many   of  the   glands 

to   the   peritoneal   surface.      The   picture    is   that   of   a   most   pronounced    diffuse 


although  the  histologic  examination  had  given  no  inkling  of  such  a 
condition.  I  had  many  more  sections  made  and  was  finally  rewarded 
by  finding  in  each  case  the  typical  picture  in  other  portions  of  the 
specimen.  Since  then  I  have  been  on  the  lookout  for  this  condition 
and  have  had  nineteen  cases. 

Adenomyoma  of  the  rectovaginal  septum  usually  starts  just  behind  - 
the  cervix,  and  on  bimanual  examination,  one  can  feel  in  this  region 
a  small,  somewhat  movable  nodule  scarcely  more  than  a  centimeter  in 
diameter.     The  rectal  mucosa  at  this  time  can  be  made  to  slide  per- 
fectly over  the  tumor. 

As  the  growth  increases  in  size,  it  spreads  out  laterally  and  at  the 
same  time  becomes  blended  with  the  adjacent  anterior  rectal  wall. 
Later  it  may  invade  the  broad  ligaments,  encircling  the  ureters,  or  may 
envelop  pelvic  nerves.  With  the  extension  of  the  growth,  it  may  push 
down  into  the  posterior  vaginal  vault  forming  definite  and  well-formed 
vaginal  polypi,  and  finally,  it  may  break  into  the  vagina. 

The  histologic  picture  is  typical  of  adenomyoma ;  even  the  vaginal 
polypi  consist  of  nonstriped  muscle  and  uterine  mucosa  covered  over 
by  vaginal  mucosa.  Where  the  growth  has  definitely  broken  through 
into  the  vagina,  we  have  normal-appearing  uterine  mucosa  lining  por- 
tions of  the  vaginal  vault. 

The  clinical  picture  in  adenomyoma  of  the  rectovaginal  septum  is 
typical.  In  the  early  stages,  the  patient  comes  complaining  of  much 
pain  just  before  and  at  the  beginning  of  the  period  especially  at  the 
time  of  defecation.  On  bimanual  examination  a  small  nodule  is  felt 
directly  behind  the  cervix. 

When  the  process  is  more  advanced,  the  growth  may  measure  2  or 
3  cm.  across  and  may  bulge  slightly  into  the  rectum,  while  in  some 
cases  there  is  already  marked  thickening  of  the  anterior  rectal  wall  for 
a  distance  of  several  centimeters,  and  at  the  period  there  may  be  some 
rectal  bleeding. 

The  growth  sometimes  encircles  one  or  both  ureters.  At  the  period, 
the  tumor  tissue  naturally  swells  up,  and  it  may  so  constrict  one  or 
both  ureters  that  there  is  a  damming  back  on  one  or  both  kidneys 
with  consequent  pain  in  the  renal  region.  In  other  cases  when  the 
pelvic  nerves  are  caught  in  the  growth,  excruciating  pelvic  pain  may 
be  experienced  as  soon  as  the  tumor  becomes  congested  at  the  time  of 
menstruation. 

Occasionally,  as  the  growth  progresses,  the  polypoid  condition  in 
the  vaginal  vault  directly  behind  the  cervix  becomes  very  prominent, 
and  in  those  cases  in  which  the  growth  breaks  through  the  vaginal 
mucosa,  there  may  be  a  menstrual  flow  from  the  vaginal  vault  even 
when  a  supravaginal  hysterectomy  has  been  performed  some  years 
before   for  uterine  myomas.     Finally,  if  nothing  is  done,  the  pelvis 


10 

may  become  so  choked  with  the  growth  that  the  patient  dies  from  the 
extreme  loss  of   blood   coupled  with  partial  intestinal  obstruction. 

In  the  early  stages  of  the  growth,  this  condition  should  be  readily 
diagnosed.  It  cannot  at  this  time  be  confused  with  any  other  pelvic 
lesion. 

Treatment. — In  the  very  early  stages  it  may  be  possible  to  open  up 
the  vaginal  vault  just  behind  the  cervix  and  remove  the  tumor.     As 


Fig.  6  (Case  1). — Adenomyotna  of  the  left  fallopian  tube.  This  section  was  taken  from 
the  left  tube  seen  in  Figure  2,  about  2  cm.  distant  from  the  uterine  horn.  Here  the  lumen 
of  the  tube  is  almost  completely  replaced  by  a  diffuse  myomatous  growth  with  isolated  glands 
or  groups  of  glands  scattered  throughout  it.  The  majority  of  the  glands  lie  in  direct  C9n- 
tact  with  the  muscle,  a  few  are  surrounded  by  the  characteristic  stroma  of  the  uterine 
mucosa.  Quite  a  number  of  the  glands  in  the  outlying  portions  have  become  dilated,  form- 
ing small  cysts.  Hitherto  I  have  never  seen  the  lumen  of  the  tube  occupied  by  an  adeno- 
myoma.      The   distal   end   of   the   tube   formed   a   hydrosalpinx. 

a  rule,  however,  it  involves  the  posterior  part  of  the  cervix  and  cannot 
be  shelled  out. 

When  the  nodule  is  1  cm.  or  more  in  diameter  and  is  still  freely 
movable,  the  abdomen  should  be  opened,  the  ureters  isolated  and  the 
uterus  with  a  cuff  of  vaginal  mucosa  removed.     If  the  vagina  is  cut 


Fig.  7  (Case  2). — Adenomyoma  of  the  rectovaginal  wall  as  seen  on  vaginal  inspection. 
This  water  color  of  the  uterus  and  accompanying  vaginal  cuff  was  made  by  Mr.  Brodel  shortly 
after  operation.  The  cervix  itself  is  practically  normal.  Projecting  from  its  surface  are  a 
few  small  Nabothian  follicles.  Just  posterior  to  the  cervix  is  a  slightly  bluish  black  cystic 
area  about  6  mm.  in  diameter.  This  bluish  black  appearance  is,  of  course,  due  to  the  accumu- 
lation of  old  menstrual  blood  in  a  small  cystic  area  in  the  adenomyoma.  The  uterus  itself 
is  little  if  any  enlarged.  For  the  appearance  of  the  adenomyoma  on  section,  see  Figure  8, 
and  for  the  microscopic  picture,  see   Figure  9. 


11 

completely  across,  one  can  then  lift  the  uterus  and  vaginal  cuff  up 
and  with  more  ease  separate  the  adherent  vaginal  cuff  from  the  rectum. 
Sometimes  it  will  be  necessary  to  remove  a  wedge  of  the  adherent 
anterior  rectal  wall  with  the  uterus. 

In  cases  in  which  the  growth  is  widespread,  a  preliminary  perma- 
nent colostomy  is  imperative.  Later  the  pelvic  structures  can  be 
removed  en  bloc.  The  removal  of  an  extensive  adenomyoma  of  the 
rectovaginal  septum  is  infinitely  more  difficult  than  a  hysterectomy  for 
carcinoma  of  the  cervix. 

When  a  hysterectomy  has  been  performed,  and  a  small  portion  of 
the  growth  has  been  left  on  the  rectum,  radium  seems  to  have  held  the 
rectal  growth  in  check. 

Since  my  last  paper  on  adenomyoma  of  the  rectovaginal  septum 
appeared  I  have  had  ten  more  cases.  The  majority  of  these  were 
early  cases,  and  it  is  in  the  early  cases  that  we  naturally  get  the  best 
results.  History  will  undoubtedly  repeat  itself.  Twenty-five  years  ago, 
a  subacute  or  chronic  appendix  was  rarely  removed ;  but  appendix 
abscesses  were  drained.  Now  the  appendix  is,  in  the  vast  majority  of 
cases,  removed  in  time.  In  less  than  ten  years,  I  feel  sure  that  the 
surgeon  will  recognize  and  operate  on  these  adenomyomas  of  the  rec- 
tovaginal septum  long  before  the  wall  of  the  rectum  or  the  broad  liga- 
ments have  been  involved.  Given  a  small  nodule  directly  behind  the 
cervix  with  little  evidence  of  pelvic  infection,  the  diagnosis  is  relatively 
certain.  If  the  abdomen  is  then  opened  and  the  rectum  is  found  lifted 
up  and  adherent  to  the  posterior  part  of  the  cervix,  the  chances  are 
nine  out  of  ten  that  an  adenomyoma  of  the  rectovaginal  septum  exists. 
When  early  operation  is  performed  in  these  cases,  a  certain  number 
of  our  "mild  pelvic  inflammatory  cases"  that  heretofore  have  gone  from 
bad  to  worse  will  be  cured.  In  the  first  week  of  November  of  this 
year,  I  saw  three  early  cases  of  adenomyoma  of  the  rectovaginal  sep- 
tum ■ — -  all  of  the  patients  being  residents  of  Baltimore. 

Recently  I  received  a  letter  from  a  surgeon  in  South  America  in 
which  he  sketched  his  case  from  the  early  to  the  inoperable  stages.  The 
history  is  so  graphically  given  that  I  believe  we  shall  all  profit  by 
hearing  it. 


Valparaiso,   Oct.    18,    1918. 


Dear   Sir : 


Having  found  your  articles  on  "Adenomyoma  of  the  Recto-Vaginal  Sep- 
tum" of  special  interest,  I  take  the  liberty  of  sending  you  details  of  a  case 
which  was  a  puzzle  to  two  other  surgeons  and  myself  until  I  luckily  saw  a 
synopsis  of  your  article  on  this  disease  in  Surgery,  Gynecology  and  Obstetrics. 
The  said  article  cleared  up  a  mystery  which  I  had  been  trying  to  solve  for 
months,  as   it  is   impossible  to  find  details  of  such   cases   in  well-known  text- 


12 

books  in  English,  German  or  French.  I  think  it  will  be  of  interest  for  you 
to  know  of  such  a  case  and  hope  you  will  have  patience  to  read  this  letter 
which  I  make  as  short  as  possible. 

Mrs.  H.,  aged  30,  nullipara,  of  good  health,  married  two  years  ago,  con- 
sulted us  (in  British  and  American  Hospital)  at  the  beginning  of  December, 
1917,  complaining  of  lumbago.  On  making  a  vaginal  examination,  we  asked 
her  about  the  menses  which  she  said  had  been  of  late  painful  on  the  right 
side;  the  uterus  was  normal  in  position,  size,  consistency,  etc.  On  the  right 
side,  the  ovary  was  painful,  but  the  puzzle  was  that  she  had  a  nodule  espe- 
cially hard  and  painful  near  the  uterus  which  we  took  to  be  localized  para- 
metritis. We  advised  her  to  take  douches,  baths,  ichthyol  suppositories,  etc., 
but  seeing  we  got  no  result  and  that  the  pain  was  excruciating  during  the 
next  period  we  decided  to  make  a  laparotomy. 

On  January  3,  we  performed  a  median  laparotomy  finding  a  right  ovary 
large  and  of  a  very  dark,  unhealthy  color.  The  nodule  mentioned  before 
was  in  the  broad  ligament  right  over  the  vagina,  and  it  being  impossible  to 
remove  it  by  abdomen,  we  resolved  to  leave  it.  The  uterus  was  normal  so 
we  left  it  as  it  was,  removing  the  ovary. 

For  three  months,  the  patient  experienced  relief  in  symptoms,  but  on  the 
fourth  month  menstruation  was  very  painful  and  the  pain  radiated  down  to 
the  thigh.  We  made  again  a  vaginal  examination  and  greatly  to  our  dis- 
a,ppointment  found  now  two  hard  nodules,  the  same  one  as  before  much 
increased  in  size  and  a  second  one  in  the  recto-vaginal  septum  which  was 
easier  to  touch  by  rectal  examination.  The  pain  on  palpation  was  terrible,  so 
we  had  to  give  the  patient  a  few  drops  of  ether  to  examine  carefully. 

Seeing  the  condition  of  afifairs,  we  had  a  consultation  with  a  third  surgeon 
and  he  was  as  much  puzzled  as  we  were.  We  decided  to  remove  these  little 
tumors  by  the  vaginal  route. 

On  May  28,  we  removed  the  two  tumors  by  the  vaginal  route  and  our 
pathologist  reported  adenocarcinoma  of  an  unusual  type. 

Looking  for  some  information  on  this  subject,  I  came  across  the  article 
already  mentioned  and  immediately  sent  for  the  more  lengthy  article  in  the 
Johns  Hopkins  Bulletin  which  I  received  the  day  before  yesterday  and  which 
has  cleared  up  the  condition  of  affairs  to  us  and  corrected  the  pathologist's 
diagnosis. 

Unluckily  our  patient's  condition  is  now  too  bad  for  us  to  think  of  doing 
a  complete  hysterectomy  and  we  think  she  will  not  live  very  long.  She  has 
not  had  as  yet  any  rectal  hemorrhage,  but  she  has  had  ovarian  insufficiency, 
very  irregular  menstruation  and  her  general  state  is  very  poor.  Locally  the 
condition  of  the  pelvis  is  one  firm  mass  as  you  say,  like  glue. 

As  I  have  not  been  able  to  procure  your  former  articles,  I  beg  your  patience 
to  answer  one  or  two  questions  by  post. 

Where  does  this  abnormal  muscular  and  glandular  tissue  come  from? 
From  the  uterus,  or  are  these  sometimes  remains  of  fetal  tissue  or  rather 
embryonic   tissue   which   suddenly   give   rise  to   the   growth? 

Thanking  you  for  the  special  service  rendered  to  us  through  your  articles 
and  hoping  you  will  let  me  know  of  any  further  researches  in  this  line, 
believe  me. 

Yours   truly, 

John   Wilson,  M.D. 


13 

REPORT     OF     CASES     OF     ADENOMYOMA     OF     THE     RECTOVAGINAL     SEPTUM 
HITHERTO     UNPUBLISHED 

Case  2  (Septum  Case  10).  ~  Adenomyoma  of  the  rectovaginal  septum 
recognized  as  an  indurated  area  just  posterior  to  the  cervix,  and  by  a  small 
bluish  black  cyst  shining  through  the  vaginal  mucosa   (Figs.  7,  8  and  9). 

History  (C.  H.  I.  No.  18650).— Mrs.  M.  L.,  aged  41,  was  admitted  to  the 
Church  Home  and  Infirmary,   March  6,   1918,  complaining  of  pain  in  the  right 


^l-' 


:--   *^  recto-vag.  septum 


of  fhf'  ntir^f  ^^^^■^^^T"'^^™^  °^  ^>^  rectovaginal  septum.  This  is  a  longitudinal  section 
rv,t<r  nth  r  •  1  ^^!'"^^  '^"^  ''=^"  1"  ^'Sure  7.  Near  the  internal  os  are  a  few  small 
normal  frtht  *Ji%"t""^  presents  the  normal  appearance.  The  anterior  vaginal  wall  is 
Tclvl'.J  ?t  P°?i  ".1°''  ''¥™^'  wall  near  the  cervix  is  an  area  of  thickening  with  small 
dark  areas  scattered  throughout  it.  On  histologic  examination  (Fig.  9),  it  presents  the 
typical  picture  of  an  adenomyoma.  '  picbcni.!,    xa<t 

lower  abdomen  associated  with  menstruation.  Her  general  health  had  not  been 
good.     She  had  had  pleurisy  in   1916. 

Her  menses  began  at  13,  were  regular,  painful  and  lasted  seven  days. 
Since  November,  1917,  the  periods  had  been  about  three  weeks  apart  and 
exceedingly  painful.     The  last  period  was   shortly  before  her  admission. 


14 

Her  present  illness  dated  back  one  and  a  half  years  when  she  had  an 
acute  attack  of  pain  in  the  right  lower  abdomen  reaching  to  the  back.  This 
was  definitelj'  associated  with  menstruation.  She  had  always  gone  to  bed  on 
the  first  day  of  the  period  and  at  times  would  become  giddy  and  faint.  For 
a  year  and  a  half,  there  had  been  a  great  deal  of  pain  in  the  right  lower 
abdomen  at  the  time  of  the  period.     This  pain  would  be  sharp  and  radiating. 

Examination. — When  the  patient  was  admitted  to  the  hospital,  she  was  in 
a  very  nervous  and  run  down  condition  and  her  period  was  just  over.  Dr. 
Edmond    H.    Teeter,    the    resident    who    made    a    pelvic    examination,    told    me 


«»^--"^  -^^i.^; 


^s.^^- 


Fig.  9  (Case  2). — Adenomyoma  of  the  rectovaginal  septum.  The  majority'  of  the  glands 
are  accompanied  by  the  characteristic  stroma  of  the  mucosa.  A  few  lie  in  direct  contact 
with  the  muscle.  For  the  appearance  before  operation,  see  Figure  7.  A  longitudinal  section 
of  the  uterus  and  rectovaginal  septum  is  shown   in  Figure   8. 


before  I  had  seen  the  patient  that  she  had  an  adenomyoma  of  the  rectovaginal 
septum.  This  was  perfect!}'  definite,  as  just  posterior  to  the  cervix  was  an 
area  of  induration  about  2  or  3  cm.  across  and  probabh-  1.5  to  2  cm.  thick. 
On   rectal   examination,   the   anterior   rectal   wall   seemed   splinted. 

Operation  and  Result. — March  26,  1918,  we  made  a  median  incision  and 
found  a  corpus  luteum  cyst,  5  cm.  in  diameter,  on  the  left  side.  The  left  tube 
and  ovary  were  at  once  removed.  The  uterus  was  graduaHj-  dissected  free  as 
far  as   its   vaginal  attachment,   and  both  ureters   were   carefullv  dissected   out. 


15 

The  vagina  was  cut  across  all  the  way  around,  after  which  adhesions  to  the 
rectum  were  got  at  from  the  under  side.  It  was  possible  to  remove  the  growth 
without  going  into  the  lumen  of  the  bowel  at  all.  There  was  considerable 
oozing  which  was  readily  checked.  Two  drains  were  left  in  the  pelvis  and 
brought  out  through  the  vagina,  one  in  the  lower  angle  of  the  incision.  The 
patient  made  a  perfectly  satisfactory  recovery  and  was  discharged  April  21,  1918. 

At  the  time  of  operation  a  small  bluish  black  cyst  was  noted  in  the  vagina 
directly  behind  the  cervix  (Fig.  7).  This  bluish  black  appearance  clearly 
indicated  that  we  were  dealing  with  an  adenomyoma. 

A  longitudinal  section  of  the  uterus  (Fig.  8)  shows  that  the  organ  is  only 
slightly  altered.  In  the  vaginal  wall  just  behind  the  cervix,  however,  is  an 
area  of  thickening  and  this  shows  the  characteristic  areas  of  hemorrhage 
invariably  associated  with  an  adenomyoma. 

Histologic  Examination  (Gyn.  Path.  No.  25514). — A  section  through  the 
posterior  vaginal  wall  at  the  point  where  the  bluish  black  cyst  was  noted 
shows  that  the  vaginal  mucosa  is  normal.  The  underlying  tissue  consists  of 
nonstriped  muscle  running  in  all  directions.  The  cyst  noted  clinically  is  lined 
with  low  cuboidal  epithelium.  It  is  partially  filled  with  old  blood  which 
presents  a  granular  appearance,  and  in  the  blood  are  exfoliated  epithelial  cells 
which  are  swollen,  have  become  spherical  and  are  filled  with  yellowish  brown 
pigment.  Some  of  the  epithelial  cells  lining  the  cyst  present  precisely  the 
same  picture.  Projecting  into  the  cyst  cavity  at  one  point  is  a  tongue-like 
mass  of  normal  uterine  mucosa.  The  surface  of  this  is  covered  with  high 
cylindric  epithelium.  Beneath  it  is  the  characteristic  stroma  of  the  mucosa, 
and  embedded  in  this  stroma  is  a  uterine  gland  which  is  continuous  far  into 
the  depth  of  the  myomatous  tissue.  Scattered  at  various  points  throughout  the 
diffuse  myoma  are  islands  of  typical  uterine  mucosa  (Fig.  9),  some  presenting 
the  usual  appearance,  others  showing  old  hemorrhage.  The  stroma  cells  of 
the  mucosa  in  such  areas  are  swollen  and  have  taken  up  yellowish  brown 
pigment. 

The  mucosa  lining  the  cervix  and  cavity  of  the  uterus   is  normal. 

In  this  case,  the  adenomyoma  is  lower  down  than  usual  and  appears  to 
have  begun  in  the  posterior  vaginal  wall  rather  than  in  the  posterior  part 
of  the  cervix. 

Case  3  (Septum  Case  11). — Adenomyoma  of  the  rectovaginal  septum  (Figs. 
10  and  11). 

History  (Gyn.  No.  24601). — Mrs.  C.  S.  F.  L.,  aged  41,  came  to  see  me  on 
Jan.  6,  1919.  She  looked  perfectly  well  but  complained  of  pain  in  the  lower 
part  of  the  abdomen  when  she  walked,  and  of  excruciating  pain  in  the  midline 
above  the  symphysis  at  the  time  of  the  periods.  She  was  also  suffering  a 
great  deal  of  discomfort  when  the  bowels  moved. 

The  patient  began  to  menstruate  at  12,  and  was  perfectly  regular.  The  flow 
for  the  last  three  years  had  been  very  free,  the  periods  persisting  for  six  days. 
There  was  a  great  deal  of  abdominal  pain  on  the  third  day.  The  last  period 
was  three  weeks  before  her  admission.  She  said  she  had  a  yellowish  discharge 
between  periods  which  at  times  was  most  irritating.  The  patient  had  had 
four  children;  no  instruments  were  used  in  the  deliveries. 

Examination. — I  found  the  abdomen  to  be  perfectly  uniform.  There  was 
a  small  hernia  at  the  umbilicus  3  mm.  in  diameter.  The  outlet  was  moderately 
relaxed,  the  cervix  was  forward  and  slightly  lacerated,  and  a  little  nodular 
thickening  about   1.5   cm.   in   diameter   could   be   felt   distinctly,   directly  behind 


16 

the  cervix.  The  body  of  the  uterus  was  not  enlarged,  but  was  sagging  back- 
ward. Rectal  examination  revealed  the  thickening  posterior  to  the  cervix 
very  clearly. 

Operation  and  Result.  —  The  patient  was  admitted  to  the  Johns  Hopkins 
Hospital,  Jan.  19,  1919,  and  operated  on  the  following  day.  After  tying  off 
the  round  ligaments  and  opening  up  the  broad  ligaments,  we  tied  the  uterine 
vessels  and  isolated  both  ureters.  We  found  a  little  puckering  and  thickening 
just  posterior  and  a  little  to  the  right  of  the  cervix  near  the  right  uterosacr^l 
ligament.  We  cut  both  uterosacral  ligaments,  turned  down  the  bladder  peri- 
toneum, controlled  the  vaginal  veins  and  then  cut  the  vagina  across  all  the 
way  around.  This  enabled  us  to  lift  the  uterus  and  rectum  well  up  so  that 
the  nodule  posterior  to  the  cervix  could  be  attacked  from  the  under  side.  The 
growth  was  gradually  loosened  and  separated  from  the  rectum  completely.  We 
were  able  to  accomplish  this  with  the  minimal  amount  of  bleeding.  The  growth 
in  the  rectovaginal  septum  was  about  1.5  cm.  in  diameter,  and  where  the  cervix 
had  become  adherent  to  the  rectum,  the  puckered  area  had  developed.  As 
we  lifted  the  cervix  away  from  the  rectum,  there  was  an  escape  of  a  little 
old  blood.  The  patient  stood  the  operation  perfectly.  We  removed  the  appen- 
dix and  put  two  drains  into  the  pelvis,  bringing  them  out  through  the  vagina. 
The  patient  made  an  excellent  recovery  and  was  discharged,  Feb.  13,  1919. 

On  Saturday  morning,.  June  29,  1919,  five  months  after  operation,  the  patient 
was  taken  with  intense  discomfort,  not  exactly  pain,  in  the  epigastrium.  This 
was  not  very  severe  and  in  spite  of  it  she  went  to  Annapolis.  On  her  return, 
there  was  no  improvement,  but  she  had  a  fair  night  with  the  aid  of  an  opiate. 
On  Sunday  morning.  Dr.  Frank  R.  Smith  was  called  but  could  discover  no  alarm- 
ing symptoms.  There  was  no  abdominal  pain,  and  no  pain  on  palpation  of  the 
abdomen.  Magnesium  citrate  and  bismuth  were  prescribed  and  the  bowels 
moved  well.  There  was  no  blood  passed  in  the  stools.  The  patient  vomited, 
but  there  was  no  unusual  odor  to  the  vomitus.  Sunday  evening,  a  hypodermic 
was  given,  and  the  patient  rested  until  2  o'clock  Monday  morning.  On  awaken- 
ing, she  complained  of  a  more  generalized  pain  and  of  a  distress  that  was 
rhythmic  in  character.  A  little  liquid  nourishment  was  given,  but  this  was 
immediately  vomited.  About  half  past  six,  an  enema  was  given,  and  the 
water  returned  clear  and  free  from  blood.  Suddenly  the  patient  fell  over, 
gasped  a  few  times  and  died.  The  husband,  who  was  a  physician,  noted  the 
rapid  heart  beat  and  abnormal  coldness  of  the  arms  some  time  before  death. 
There  was  no  clamminess  or  dyspnea  noted  at  this  time. 

Necropsy  Findings  (J.  H.  H.  Necropsy  No.  5933). — This  was  performed  by 
Dr.  R.  G.  Mills.  When  the  abdomen  was  opened  the  omentum  was  found 
firmly  adherent  to  the  under  surface  of  the  scar.  At  no  point  were  there 
adhesions  between  the  omentum  and  loops  of  intestine.  As  the  intestines 
came  into  view,  they  appeared  somewhat  distended,  a  little  dark  in  color.  The 
lowermost  loop  was  very  dark  and  purplish,  and  the  serosa  of  this  dark 
colored  loop  had  to  some  extent  lost  its  luster,  and  the  subcutaneous  tissue 
appeared  infiltrated  with  blood.  There  was  a  small  amount  of  free,  clear 
straw-colored  fluid  in  the  peritoneal  cavity,  and  there  were  a  number  of  small 
adhesions  that  connected  the  various  loops  of  intestine.  It  was  rather  dif- 
ficult to  unravel  the  abdominal  picture. 

Dr.  Mills'  summing  up  is  as  follows  :  "Beginning  at  the  point  where  the 
jejunum  joins  the  ileum  the  bowel  passes  beneath  the  mass  of  adherent 
intestine,  it  passes  under  a  fold  of  mesentery,  it  emerges  below  in  the  region 
of  the  cecum  and  is  there  united  with  another  loop  of  bowel  by  a  long,  slender 


17 

strong  band  of  adhesions.  The  ileum  now  passes  into  a  long  loop  that  circles 
around  and  is  adherent  once  more  to  the  long  adhesion  just  mentioned.  Just 
above  this  attachment  the  ileum  is  kinked  into  an  S-shaped  mass  as  the  result 
of  adhesions  which  attach  contiguous  mesenteric  surfaces.  The  bowel  then 
passes  on  in  another  loop  returning  beneath  this  long  slender  adhesion.  At 
this  point  the  lumen  of  the  ileum  is  abruptly  decreased  in  caliber  and  beyond 
this  point  is  much  smaller.  At  the  point  of  constriction,  the  serosa  is  very 
deeply  injected  and  somewhat  consolidated.  The  bowel  is  much  firmer  by 
reason  of  a  hemorrhage  at  the  point  where  obstruction  occurs. 

"Subsequent  to  operation,  it  is  probable  that  adhesions  formed  between 
contiguous  loops  of  bowel.  These  have  organized,  producing  distortion  of 
the  lumen  of  the  bowel.  The  adhesions  are  probably  responsible  for  the  long 
slender  adhesion  above  mentioned.  Probably  at  the  onset  of  the  present  acute 
attack  a  twist  of  the  whole  mass  has  occurred  producing  in  efifect  a  volvulus. 
This  has  thrown  unusual  tension  on  the  narrow  band  which,  producing  a 
bridge-like  form,  has  allowed  a  loop  of  ileum  to  pass  beneath  it." 


Adleno  myonta 


Fig.  10  (Case  3). — Adenomyoma  of  the  rectovaginal  septum.  Springing  from  the  pos- 
terior surface  of  the  uterus  are  a  few  small  myomas.  Growing  from  the  posterior  surface 
of  the  cervix  just  below  the  peritoneal  attachment  is  a  rough  nodular  growth.  This  on 
histologic  examination  showed  typical  adenomyoma  (Fig.  11).  As  a  rule,  I  never  remove 
normal  ovaries,  but  in  some  cases  of  adenomyoma  of  the  rectovaginal  septum  it  is  necessary 
to  leave  a  small  portion  of  the  growth  attached  to  the  rectum,  and  if  the  ovaries  are  saved 
there  appears  to  be  a  tendency  for  the  remaining  portion  of  the  adenomyoma  to  continue 
to  grow. 

Dr.  Mills'  findings  disclose  clearly  the  fact  that  intestinal  adhesions  had 
followed  the  abdominal  operation  and  that  several  months  later  there  was  a 
sudden  volvulus  of  the  adherent  intestinal  mass  producing  acute  obstruction. 
It  is  remarkable  to  find  a  patient  succumbing  so  quickly  after  the  symptoms 
of  partial  obstruction  developed.  It  will  be  noted,  however,  that  the  upper 
part  of  the  small  bowel  was  much  involved.  In  such  cases  alarming  symp- 
toms usually  develop  relatively  early. 

Examination  of  Specimen  (Gyn.  Path.  No.  24657). — The  specimen  consists 
of  the  uterus  with  the  appendages  intact  (Fig.  10).  The  uterus  is  9  cm.  long, 
5  cm.  broad  and  5  cm.  in  its  anteroposterior  diameters.  Both  the  anterior  and 
posterior  surfaces  are  smooth.  In  the  posterior  wall  of  the  uterus  are  two 
small  fibroids.     These  project  a  little  from  the  surface.     Springing  from  the 


18 

posterior  wall  of  the  cervix  is  a  small,  irregular  growth  about  1.5  by  1  cm. 
This  is  intimateh'  blended  with  the  cervical  wall.  In  the  depth,  it  contains 
several  small  bluish  black  areas. 

There  is  a  slight  rolling  out  of  the  cervical  mucosa.  Situated  in  the  ante- 
rior wall  of  the  uterus  is  a  m3'oma,  1.5  cm.  in  diameter.  The  uterine  mucosa 
is  normal. 

The  appendages  on  both  sides  are  perfectly  normal. 

Histologic  Examination. — The  mucosa  of  the  vaginal  and  cervical  portions 
of  the  cervix  is  normal.  The  growth  on  the  posterior  surface  of  the  cervix 
consists  in  large  measure  of  fibrous  tissue.  It  also  contains  a  moderate  amount 
of  nonstriped  muscle.  Here  and  there  in  this  diffuse  growth  are  irregular 
deposits  of  uterine  mucosa  (Fig.  11).  This  in  some  places  presents  the  nor- 
mal picture,  at  other  points  it  shows  a  mild  grade  of  hypertrophy.  Here  and 
there  the  stroma  of  the  mucosa  shows  hemorrhage. 

We  are  dealing  with  a  typical  adenomyoma  of  the  rectovaginal  septum. 


^5s|^g^v^^^ 


i£l^^^^^^:: 


"i^^i^-'s*^ 


Fig.  11  (Case  3). — Adenomyoma  of  the  rectovaginal  septum.  For  the  gross  specimen  see 
Figure  10.  The  tissue  was  very  difficult  to  cut,  hence  the  imperfect  section.  The  glands 
of  the  growth  are  surrounded  by  the  characteristic  stroma. 

Case  4  (Septum  Case  12). — Adenomyoma  of  the  rectovaginal  septum  (Figs. 
12  and  13). 

History  (Gyn.  No.  24585).— B.  L.,  aged  25,  admitted  to  the  Johns  Hopkins 
Hospital,  Jan.  21,  1919,  had  had  a  dilatation  and  curettement  at  the  Church 
Home  and  Infirmary  following  a  miscarriage  in  June,  1910.  On  Oct.  28,  1911, 
she  was  admitted  to  the  Johns  Hopkins  Hospital,  and  a  diagnosis  of  chronic 
pelvic  inflammation  was  made.  I  performed  a  dilatation  and  curettement, 
removed  the  right  tube,  the  left  tube  and  ovary  and  appendix.  Laboratory 
examination  (Gyn.  Path.  No.  16635)  revealed  acute  endometritis,  and  (Gyn. 
Path.  No.  16625)  a  double  pyosalpinx,  a  relatively  normal  appendix,  a  cystic 
left  ovar}\  There  was  nothing  in  the  clinical  history  at  that  time  to  indicate 
adenomvoma. 


19 

The  patient  began  to  menstruate  at  13,  and  was  regular.  Since  the  opera- 
tion in  1911,  the  periods  had  occurred  at  intervals  of  from  fifteen  to  twenty- 
one  days  and  had  lasted  from  six  to  seven  days.  She  formerly  had  little 
menstrual  pain,  but  for  the  last  year  the  discomfort  had  been  growing  worse. 
The  pain  usually  started  when  the  period  commenced,  it  might  last  for  a 
couple  of  days.  It  was  dragging,  dull-aching  in  character,  and  she  also  had 
pain  in  the  back.  Her  last  menstrual  period  occurred  after  her  admission 
to  the  hospital.  There  had  been  no  intermenstrual  bleeding  except  on  one 
occasion,  a  year  before,  after  severe  exertion.  There  was  a  slight  leukorrhea 
just  before  and  after  the  period.     The  patient  had  been  married  two  years  and 


Fig.  12  (Case  4). — Adenomyoma  low  down  in  the  rectovaginal  septum.  The  cervix  has 
been  drawn  strongly  to  the  left.  On  the  posterior  surface  high  up  are  two  small  cysts.  One 
stands  out  prominently,  the  other  is  rather  hazy.  Just  below  them,  that  is,  toward  the 
external  os,  the  mucosa  is  definitely  puckered.  The  low  position  of  the  growth  enabled  us 
to  remove  it  with  ease  through  the  vagina.     For  the   histologic  picture   see   Figure    13. 

a  half.  She  had  had  no  children,  but  she  had  had  a  miscarriage  at  six  weeks 
in  1910.  In  1913,  a  small  lump  was  felt  in  the  vaginal  wall  behind  the  cervix. 
At  that  time  it  was  no  larger  than  a  pinhead.  It  had  gradually  increased  in 
size  and  she  now  had  two  small  nodules.     These  were  not  tender. 

Examination. — On  vaginal  examination,  the  cervix  was  found  to  be  normal 
in  size.  The  body  of  the  uterus  was  anteposed,  and  in  good  position.  There 
was  no  thickening  on  either   side.     In  the  vaginal  vault,  slightly  to  the   right 


20 

of  the  cervix,  were  two  elastic  spherical  bodies  each  about  5  mm.  in  diameter. 
They  lay  close  together  and  seemed  really  to  form  part  of  the  same  nodule. 
They  were  not  fixed  and  occasioned  no  discomfort.  When  a  speculum  was 
introduced  to  the  side  of  the  cervix,  one  saw  two  small  bluish  cysts  with 
slight  puckering  of  the  vaginal  mucosa  about  the  center  of  each  of  these  small 
thickenings    (Fig.   12). 

Operation. — Jan.  25,  1919,  I  drew  the  cervix  well  over  to  the  left,  and  on 
the  right  side  of  the  vaginal  vault  lateral  to  the  cervix  there  appeared  two 
small  areas  darkish  blue  in  color.     These  were  incorporated  in  two  small  tumors 


Fig.  13  (Case  4.). — A  small  cyst  in  an  adenomyoma  of  the  rectovaginal  septum.  This  is 
one  of  the  small  cysts  noted  in  Figure  12.  It  is  lined  with  one  layer  of  cylindric  epithelium 
of  the  body  type,  and  extending  into  the  cavity  are  several  small  projections.  The  cyst 
contained  blood  and  some  exfoliated  epithelium.  At  some  points,  the  cyst  epithelium  lay 
directly  on  the  underlying  muscle,  in  other  places  it  was  separated  from  the  muscle  by  a 
definite  stroma. 

lying  deep  beneath  the  vaginal  mucous  membrane.  I  made  an  elliptical  incision 
including  these  two  small  tumors.  Thej^  were  rem.oved  without  any  difficulty 
and  the  vaginal  incision  closed.  The  patient  was  discharged,  February  5,  in 
good  condition. 

Examination  of  Specimen  (Gyn.  Path.  No.  24652). — The  larger  cyst  reaches 
a  diameter  of  6  by  4  mm.  Both  cysts  are  surrounded  by  a  definite  layer  of 
muscle  arranged  circularly.  The  cysts  are  lined  by  one  layer  of  cylindric 
epithelium  which  is  somewhat  folded.  In  one  of  the  cysts  are  definite  pro- 
jections (Fig.  13).  Both  cysts  contained  blood  and  in  the  underlying  stroma 
and  muscle  are  quantities  of  yellowish  brown  pigment. 


21 

This  was  undoubtedly  another  adenomyoma.  It  was  situated  much  lower 
down  than  usual  and  we  were  accordingly  able  to  remove  it  with  the  minimal 
amount  of  difficulty. 

Case  S  (Septum  Case  13). — Adenomyoma  of  the  rectovaginal  septum  (Figs. 
14  and   15). 

History  (Gyn.  No.  24864). — A.  A.,  aged  26,  was  admitted  to  the  Johns 
Hopkins  Hospital,  May  2,  1919,  complaining  of  bearing  down  pains  in  the 
pelvis  and  of  backache.  The  patient's  mother  died  of  some  form  of  cancer. 
Menstruation  began  at  13,  was  regular  and  lasted  from  three  to  four  days. 
She  had  pain  for  the  first  day,  cramplike  in  character.  There  was  no  inter- 
menstrual bleeding.     The  patient  has  been  married  seven  years.     She  has  had 


Aa. 

myom 


Fig.  14  (Case  5). — Adenomyoma  of  the  rectovaginal  septum.  Attached  to  the  posterior 
surface  of  the  uterus  are  a  few  adhesions.  Springing  from  the  posterior  surface  of  the 
cervix  below  the  peritoneal  attachment  is  a  well  defined  nodule,  2  by  1  cm.  For  the  his- 
tologic picture  of  this  nodule   see  Figure   15. 

one  child.  About  a  year  ago  she  began  to  have  a  dragging  sensation  in  the 
lower  abdomen;  this  was  no  worse  at  the  periods.  The  symptoms  had  increased 
in  severity. 

Examination. — The  patient  was   a  well   developed  woman.     The  outlet  was 
relaxed,   the   cervix   was    lacerated.     Behind   the   cervix   was    a   nodule    about  - 
1.5  cm.  in  diameter.     This  was  not  very  tender.     The  uterus  itself  was  normal 
in   size  and   in  good  position.     On   the   left   side  there  was   some  thickening 
probably  due  to  a  prola,psed  ovary.    The  patient  had  no  hemorrhoids. 

Dr.  H.  N.  Shaw,  the  resident  gynecologist,  immediately  thought  of  adeno- 
myoma of  the  rectovaginal  septum. 

Operation. — May  3,  under  anesthesia,  I  confirmed  Dr.  Shaw's  impressions. 
On  examination,  I  found  that  the  rectum  was  attached  to  the  nodule  posterior 


22 

to  the  cervix.     The  rectal  wall  did  not  seem  to  be  invaded  but  was  somewhat 
puckered  at  this  point. 

When  the  abdomen  was  opened,  a  little  puckered  area  could  be  seen  just 
posterior  to  the  cervix.  The  rectum  here  was  lifted  u,p  and  had  become  adherent 
to  the  puckered  area.  The  picture  was  that  of  a  typical  early  adenomyoma  of 
the  rectovaginal  septum.  The  operation  was  begun  by  tying  and  cutting  the 
round  ligaments  on  each  side.  The  right  ovarian  vessels  were  clamped  and 
cut.  We  decided  to  leave  the  left  ovary.  After  freeing  the  broad  ligaments 
on  each  side,  they  were  spread  widely  apart  and  the  inner  flap  was  split  down 
to   the   region   of  the   ureter.     Both   ureters   were   now   dissected   out   and   the 


Fig.    15    (Case    S). — Adenomyoma   of   the   rectovaginal    septum.      This    section    is  from    the 

adenomyoma   springing   from    the   posterior    part   of   the    cervix    in    Figure    14.      The  muscular 

tissue   is   very   dense.      Scattered   throughout   it   are    isolated    glands    surrounded    by  the    char- 
acteristic stroma. 


uterine  vessels  ligated.  The  dissection  was  now  carried  down  far  in  the 
vaginal  vault,  and  the  vaginal  veins  were  clamped  and  tied.  After  sufficient 
exposure  had  been  obtained  in  this  manner,  the  uterosacral  ligaments  were 
cut  and  the  uterus  drawn  well  out.  The  vagina  was  then  cut  across  well 
below  the  nodule  in  the  rectovaginal  septum  and  the  thickened  vaginal  wall 
was  gradually  dissected  free  from  the  rectum.  The  bowel  was  in  no  way 
damaged.  The  appendix  was  removed,  a  small  drain  was  left  in  the  pelvis 
and  brought  out  through  the  vagina,  and  the  abdominal  incision  closed.  The 
patient  left  the  table  in  excellent  condition.    She  was  discharged,  May  25,  1919. 


2}> 

Examination  of  Specimen  (Gyn.  Path.  No.  24989).— The  specimen  consists 
of  the  uterus,  right  tube  and  ovary  and  appendix.  The  uterus  is  8  cm.  long, 
6  cm.  broad  and  4.5  cm.  in  its  anteroposterior  diameters.  The  anterior  sur- 
face of  the  uterus  is  smooth,  the  posterior  surface  is  covered  by  a  few  shaggy 
adhesions,  but  is  for  the  most  part  smooth.  Projecting  from  the  posterior 
surface  of  the  cervix  near  the  internal  os  is  a  nodule  2  by  1  cm.  (Fig.  14). 
This  is  irregular.  It  blends  into  the  cervical  tissue,  but  the  line  of  demarca- 
tion is  sharply  defined.  Its  superficial  portion  invades  the  surrounding  adi- 
pose tissue.  It  contains  a  few  minute  brownish  areas.  The  vaginal  portion 
of  the  cervix  shows  some  laceration.  The  uterine  mucosa  reaches  6  mm.  in 
thickness. 

The  right  tube  is  normal.  The  right  ovary  contains  an  unruptured  corpus 
luteum,  and  the  peritoneum  over  this  area  has  been  adherent. 

Histologic  Examination.— Tht  mucosa  of  the  vaginal  portion  of  the  cervix 
is  normal.  The  cervical  glands  present  the  usual  appearance.  The  nodule  pro- 
jecting from  the  posterior  surface  of  the  cervix  consists  of  nonstriped  muscle 
and  fibrous  tissue.  Scattered  throughout  it  are  small  irregular  islands  of  uterine 
mucosa  (Fig.  15).  Near  the  point  where  the  growth  was  attached  to  the  rectum 
is  a  rather  large  area  of  mucous  membrane  showing  the  characteristic  gland 
hypertrophy  now  and  then  noted  in  the  mucosa  of  the  body  of  the  uterus. 
This  is  a  typical  case  of  adenomyoma  of  the  rectovaginal  septum. 
Case  6  (Septum  Case  14).  —  Extensive  adenomyoma  of  the  rectovaginal 
septum;  extension  to  the  surface  of  the  right  fallopian  tube;  uterine  mucosa 
on  the  surface  of  the  right  ovary   (Figs.  16,   17,  18,  19,  20  and  21). 

History  (Gyn.  No.  24887).— L.  G.,  aged  40,  white,  was  admitted  to  the  Johns 
Hopkins  Hospital,  May  9,  1919,  complaining  of  dysmenorrhea  and  menorrhagia. 
The  patient  had  been  in  the  hospital   in   1912    (Gyn.  No.   18377).     At  that 
time    I   performed   a   partial    resection    of   both    ovaries,    released    pelvic    adhe- 
sions and  removed  the  appendix. 

She  was  again  admitted  to  the  hospital  in  1915  (Gyn.  No.  20850).  At  that 
time  Dr.  Neill,  the  resident,  incised  and  cauterized  a  Bartholin's  gland  abscess. 
The  patient's  menses  were  fairly  regular  and  lasted  seven  days.  There  was 
a  very  profuse  flow.  The  last  period  was  April  20.  There  was  no  intermen- 
strual bleeding.  The  patient  had  always  had  very  severe  dysmenorrhea.  This 
had  become  more  distressing  during  the  last  year.  The  most  acute  pain  was 
experienced  a  day  before  the  period  started.  During  the  twenty-four  hours 
before  the  onset  of  the  flow  the  patient  was  nauseated,  vomited,  had  extreme 
abdominal  pain  and  pain  in  the  back.  These  symptoms  were  getting  worse. 
The  patient  had  been  married  fifteen  years.  She  had  one  child,  fourteen 
years  ago,  and  no  miscarriages. 

Examination.— Tht  patient  was  a  rather  delicate,  undernourished,  middle- 
aged  woman.  Her  hemoglobin  was  75  per  cent.,  white  blood  cells,  11,000.  The 
lower  abdom,en  was  prominent,  due  to  a  hard  mass  extending  up  from  the 
pelvis  and  reaching  to  within  about  4  cm.  of  the  umbilicus.  The  outlet  was 
moderately  relaxed  and  the  cervix  was  high  up  in  the  vaginal  vault.  It  was 
continuous  with  the  abdominal  tumor. 

Operation.— M^Y  12,  1919,  on  examination  under  ether,  the  pelvis  was  found 
to  contain  a  large  mass  about  the  size  of  a  five-months'  pregnancy.  On  the 
surface  of  this  and  also  posteriorly,  a  hard  nodule  could  be  felt.  In  the 
rectovaginal  septum  on  the  left  side  was  a  dense  indurated  mass. 


24 


When  the  abdomen  was  opened,  the  uterus  was  found  to  be  quite  sym- 
metrical and  enlarged  from  the  fundus  to  the  cervix.  The  right  tube  was 
filled  with  fluid  and  was  adherent  to  the  uterus.  The  intestines  were  adherent 
to  the  posterior  surface  of  the  uterus.  The  culdesac  was  indurated,  and  the 
rectum  was  adherent  well  up  on  the  posterior  surface  of  the  uterus.  It  was 
also  firmly  attached  to  the  left  broad  ligament.  The  left  tube  was  partly 
obscured  by   adhesions,   and   the   left   ovary  was   buried   in   adhesions.     As   a 


Adeno  myoma 


myoma 
all  of  tube 


Adeno  myoma 
In  ovary 


Cervix 


Submucous  fibroma 


Fig  16  (Case  6). — Widespread  adenomyoma  of  the  rectovaginal  septum;  extension  to  the 
surface  of  the  right  ovary  and  tube.  The  supravaginally  amputated  uterus  was  13  cm.  kmg 
and  11  cm.  broad.  Its  anterior  surface  was  smooth,  its  posterior  surface  covered  by  adhe- 
sions. Occupying  the  posterior  surface  of  the  cervix  and  extending  well  up  on  the  body  ot 
the  uterus  was  a  diffuse  and  hard  growth.  This  consisted  of  typical  adenomyoma  (i^igs.  17, 
18  and  19).  The  right  tube  and  ovary  formed  one  large  sohd  mass,  and  on  the  surface  ot 
both  tube  and  ovary  was  typical  uterine  mucosa  (Figs.  20  and  21).  This  is  the  most  wide- 
spread   distribution   of    an    adenomyoma    of   the    rectovaginal    septum   that    I    have    ever    seen. 

matter  of  fact,  the  left  tube  and  ovary  and  the  sigmoid  flexure  formed  one 
solid  mass. 

The  operation  was  begun  by  separating  some  loops  of  bowel  from  the  pelvis, 
then  the  left  round  ligament  was  cut;  the  left  tube  and  ovary  were  clamped 
off  at  the  uterus  and  left  temporarily  in  place.    The  bladder  was  pushed  down 


25 


.2  6 

-"  o 
O   1-. 


s 

-^  u 


26 

and  the  right  round  ligament  was  cut,  the  right  ovarian  vessels  were  then 
clamped  and  cut.  After  this  procedure,  it  was  found  possible  to  lift  the  uterus 
well  up,  and  we  then  realized  that  without  doubt  we  were  also  dealing  with 
an  adenomj'oma  of  the  rectovaginal  septum.  Dissection  was  gradually  carried 
down  on  the  posterior  surface  of  the  cervix  as  far  as  possible,  and  a  supra- 
vaginal amputation  performed.  Better  exposure  could  now  be  obtained,  and 
the  stump  of  the  cervix  was  dissected  free.  The  rectum  was  densely  adherent 
to  the  hard  mass  occupying  the  lower  and  posterior  part  of  the  uterus,  the 
posterior  part  of  the  cervix  and  the  adjacent  rectovaginal  septum.  During 
manipulation  a  little  dark  blood  escaped   from  the   rectovaginal   septum.     To 


Fig.  18  (Case  6). — This  picture  is  an  enlargement  of  the  area  a  in  Figure  17.  One  sees 
numerous  uterine  glands  surrounded  by  the  typical  stroma  of  the  mucosa.  A  few  of  the 
glands  are  dilated.  In  the  upper  part  of  the  picture  is  an  area  of  characteristic  stroma 
covered  over  by   one  layer  of  cylindric   epithelium. 

have  removed  entirely  the  diffuse  growth  of  the  rectovaginal  septum  would 
have  been  an  impossibility.  As  it  was,  it  was  one  of  the  most  difficult  hyster- 
ectomies I  ever  attempted.  The  ureters  were  not  exposed  on  either  side,  but 
they  could  be  seen  through  the  pelvic  peritoneum ;  they  were  well  removed 
from  the  point  where  the  uterine  vessels  were  controlled. 

The  cut  edge  of  the  vaginal  mucosa  was  then  controlled  all  the  way  round, 
and  then  the  broad  ligaments  were  obliterated  as  far  as  possible.  Notwith- 
standing our  attempts  to  leave  a  smooth  surface,  a  small  amount  of  raw  area 
still  remained  in  the  culdesac.     Two  cigaret  drains  were  placed   in  the  pelvis 


27 

and  brought  out  through  the  vagina.  The  abdomen  was  then  closed  in  the 
usual  manner.  The  patient  lost  a  considerable  amount  of  blood  during  the 
operation  but  left  the  table  in  good  condition. 

She  was  discharged,  June  1,  1919.  There  was  no  induration  in  the  pelvis 
and  she  felt  well. 

We  shall  watch  the  subsequent  history  in  this  case  with  a  good  deal  of 
interest  as  some  of  the  adenomyomatous  growth  was  of  necessity  left  adherent 
to  the  rectum. 

Examination  of  Specimen  (Gyn.  Path.  No.  25003). — The  specimen  consists 
of  the  enlarged  uterus  with  its  detached  cervix  and  of  the  appendages  from 
both  sides 

The  supravaginall}^  amputated  uterus  is  13  cm.  long  and  11  cm.  in  its 
anteroposterior  diameters.  The  anterior  surface  of  the  uterus  is  smooth,  the 
posterior  surface  at  the  fundus   is  covered  by  shaggy  adhesions.     The  greater 


^JfpfS**:. 


Fig.  19  (Case  6). — Adenomyoma  of  the  rectovaginal  septum.  This  is  a  section  from  the 
adenomyoma  of  the  rectovaginal  septum  shown  in  Figure  16.  The  uterine  mucosa  is 
unusually  abundant,  forming  fully  half  of  the  section.  Even  with  the  very  low  power  it  will 
be  noted  that  many  of  the  glands  show  hypertrophy. 


part  of  the  posterior  surface  over  an  area  approximately  7  cm.  from  above 
downward  and  12  cm.  from  side  to  side  presents  a  rough  and  ragged  appear- 
ance. This  is  the  area  that  will  prove  to  be  of  the  greatest  interest,  the 
appearance  being  due  to  a  widespread  adenomyoma  occupying  the  posterior 
surface  of  the  uterus  and  cervix  (Fig.  16). 

The  increase  in  size  of  the  uterus  is  in  large  measure  due  to  the  presence 
of  a  submucous  myoma  10  cm.  in  length.  This  projects  into  the  uterine  cavity 
from  the  posterior  wall.  The  anterior  wall  of  the  uterus  varies  from  1.5  to 
2  cm.  in  thickness,  and  the  mucosa  from  1  to  7  mm.  The  mucous  membrane 
over  the  surface  of  the  submucous  myoma  is  very  thin,  in  most  places  being 
not  over  0.5  mm.  thick. 


28 

The  widespread  raw  area  which  occupies  the  greater  part  of  the  posterior 
surface  of  the  uterus  has  a  very  ragged  appearance.  As  noted  from  the 
description  of  the  operation,  this  area  had  literally  to  be  cut  away  from  the 
rectum.  On  incising  the  raw  area,  one  notes  a  coarse  striation  of  the  tissue, 
and  at  various  points  are  small  brownish  specks.  Histologic  examination  will 
show  that  this  is  adenomyomatous  tissue. 

The  lower  portion  of  the  cervix  was  removed  after  the  fundus  had  been 
taken  away.  The  vaginal  portion  of  the  cervix  shows  some  eversion  of  the 
cervical  mucosa. 

Right  Side  :  The  tube  and  ovary  form  a  conglomerate  mass  which  has  been 
densely  adherent  to  the  side  of  the  uterus  as  well  as  to  the  surrounding  struc- 
tures.     Notwithstanding    this    the    fimbriated    end    of    the    tube    is    patent    and 


Fig.  20  (Case  6). — Extension  of  an  adenomyoma  of  the  rectovaginal  septum  to  the 
surface  of  the  adherent  fallopian  ttibe.  The  gross  appearance  of  the  tube  is  shown  in  Figure 
16.  The  folds  of  the  tube  look  relatively  normal.  The  solid  black  areas  are  blood  vessels. 
On  the  surface  of  the  tube  at  a-d  is  an  area  of  typical  uterine  mucosa.  It  really  looks  as  if 
the  widespread  adenomyoma  of  the  rectovaginal  septum  has  literally  flowed  over  on  the 
surface  of  the  tube. 


appears  relatively  normal.  The  tubo-ovarian  mass  measures  10  cm.  in  length 
and  at  one  point  reaches  a  diameter  of  5  cm.  It  is  impossible  to  trace  the 
continuity  of  the  tube  in  its  middle  portion  where  it  is  intimately  attached  to 
the  ovary  and  is  covered  by  adhesions.  The  ovary  contains  at  least  two  small 
corpora  lutea  cysts. 

Left  Side :  The  appendages  form  an  inseparable  mass,  6  cm.  long  and  about 
4  cm.  in  diameter.  They  are  embedded  in  adhesions,  but  the  fimbriated  end 
of  the  tube  is  patent. 


29 


Fig.  21  (Case  6). — Uterine  mucosa  on  the  surface  of  the  ovary  in  a  case  of  adenomyoma 
of  the  rectovaginal  septum.  For  the  gross  appearance  of  the  ovary  see  Figure  16.  The 
miniature  uterine  cavity  on  the  surface  of  the  right  ovary  is  represented  by  a.  The  lining 
mucosa  resembles  in  every  particular  that  of  the  body  of  the  uterus.  Some  of  the  glands 
show  hypertrophy.  The  mucosa  of  the  adenomyoma  of  the  rectovaginal  septum  seems  to 
have  overflowed  to  the  surface  of  the  adherent  ovary.  The  same  condition  was  noied  on 
the  surface  of  the  corresponding  tube    (Fig.   20). 


30 

Flistologic  Examination-. — Sections  from  the  cervical  mucosa  show  that  it 
is  normal  (Fig.  17).  Sections  from  various  portions  of  the  large  raw  area 
on  the  posterior  surface  of  the  body  of  the  uterus  and  cervix  present  an  amaz- 
ing picture  (Figs.  17,  18  and  19).  The  tissue  consists  in  large  measure  of 
nonstriped  muscle,  and  scattered  everywhere  throughout  this  are  tremendous 
areas  of  perfectly  normal  looking  uterine  mucosa.  So  abundant  is  the  mucosa 
in  many  places  that  it  forms  at  least  one  half  or  two  thirds  of  the  section. 
This  mucous  membrane  in  many  places  shows  a  tendency  toward  hj'pertrophy 
(Fig.  19).  Its  stroma  shows  a  considerable  amount  of  hemorrhage,  and  here 
and  there  a  gland  is  dilated  reaching  a  millimeter  or  more  in  diameter.  This 
is  the  most  widespread  distribution  of  an  adenomyoma  on  the  posterior  sur- 
face of  the  uterus  that  I  have  ever  seen.    . 

The  mj-oma  occupying  the  posterior^  wall  of  the  uterus  and  projecting  into 
the  uterine  cavity  shows  much  hyaline  degeneration. 

Sections  from  the  right  uterine  cornu  show  that  the  tube  at  this  point  is 
perfectly  normal,  but  sections  further  out,  although  showing  a  normal  mucosa, 
reveal  typical  areas  of  uterine  mucosa  on  the  surface  of  the  tube  (Fig.  20). 
One  gathers  the  impression  that  the  uterine  mucosa  from  the  diffuse  adeno- 
mj'oma  on  the  posterior  surface  of  the  cervix  and  uterus  has  overflowed  upon 
the  adherent  tube. 

On  the  surface  of  and  intimately  attached  to  the  right  ovarj^  is  a  miniature 
uterine  cavity  (Fig.  21);  The  glands  of  its  mucosa  show  a  moderate  hyper- 
trophy. Other  sections  from  the  same  ovary  show  a  diffuse  adenomyoma  inti- 
mately blended  with  the  ovarian  tissue,  so  intimately  attached  that  no  line  of 
demarcation  can  be  detected.  It  must  be  remembered,  however,  that  this  ovary 
was  firmly  glued  to  and  continuous  with  the  diffuse  adenom3'oma  occupying  the 
posterior  surface  of  the  uterus. 

Case  7  (Septum  Case  15). — Adcnoviyonia  of  the  rectovaginal  septum  (Figs. 
22  and  23). 

History  (Gyn.  No.  24984). — C.  B.,  aged  36,  white,  entered  the  Johns  Hop- 
kins Hospital,  June  12,  1919,  complaining  of  pain  in  the  left  lower  abdomen 
at  the  menstrual  period.  She  also  had  severe  headaches.  The  menses  began 
at  13,  were  regular  until  six  months  ago  when  they  appeared  three  times  in  a 
month;  the  last  period  was  on  June  7,  the  one  previous  on  May  28.  During  the 
last  two  months  the  pain  had  been  severe  in  the  left  lower  abdomen.  She  gave  no 
history  of  rectal  bleeding  at  the  menstrual  period. 

Examination. — On  pelvic  examination,  the  cervix  was  found  low  in  the 
vagina.  The  body  of  the  uterus  had  dropped  back,  was  irregular  and  nodular 
in  outline.  In  the  left  side  of  the  pelvis  was  a  movable,  cystic,  rather  tense 
mass  about  8  cm.  in  diameter. 

Operation. — On  examination  under  anesthesia  in  addition  to  the  above  find- 
ings, a  small  cystic  mass  could  be  felt  on  the  right.  June  14,  the  abdomen 
was  opened  and  two  cysts  with  rather  opaque  looking  walls  were  seen  in  the 
pelvis.  One  lay  up  in  under  the  left  broad  ligament,  the  other  occupied  the 
floor  of  the  culdesac;  both  contained  dark  chocolate-colored  fluid,  in  other 
words,  there  was  a  corpus  luteum  cj'st  on  each  side.  The  cysts  were  resected 
and  a  small  piece  of  ovarj'  was  left  on  both  sides.  After  removal  of  the  cj^st, 
there  still  remained  a  small  adherent  mass  between  the  cervix  and  rectum,  and 
there  was  no  doubt  that  an  adenomyoma  of  the  rectovaginal  septum  existed. 
The  ureters  were  isolated,  the  uterus  freed  on  all  sides  and  the  vagina  cut 
across.  A  small  amount  of  adenomyomatous  tissue  was  left  adherent  to  the 
rectum.     Near  the  completion  of  the  operation,  it  was  found  that  the  left  tube 


31 

and  ovary  had  a  very  poor  blood  supply,  and  for  this  reason  they  were  removed. 
The  appendix,  which  was  very  long,  was  also  removed.  A  drain  was  laid  in 
the  pelvis  and  brought  out  through  the  vagina.  The  abdomen  was  then  closed. 
A  considerable  amount  of  blood  was  lost  during  the  operation.  The  patient 
left  the  table  in  fair  condition.  She  was  discharged,  July  5,  1919,  in  good 
condition. 

Examination  of  Specimen  (Gyn.  Path.  No.  25120). — The  specimen  consists 
of  the  uterus  and  of  the  much  mutilated  a,ppendages  together  with  the  appendix. 

The  uterus  is  11  cm.  long,  6  cm.  broad  and  4  cm.  in  its  anteroposterior 
diameters  (Fig.  22).  The  anterior  surface  is  smooth.  The  posterior  surface 
almost  to  the  top  of  the  fundus  is  covered  by  adhesions.  Springing  from  the 
posterior  surface  of  the  cervix  is  a  raised  hard  area  2.5  by  2  cm.  The  tissue 
here  is  exceptionally  hard,  and  on  section  it  presents  a  brownish  black  appear- 
ance.    It  extends   into  the  posterior  cervical  wall  nearly   1   cm.  and   spreads 


Adhesions 


.deno  TYiyonta 


Fig.  22  (Case  7). — Adenomyoma  of  the  rectovaginal  septum.  The  posterior  surface  of 
the  fundus  is  partially  covered  by  adhesions.  Springing  from  the  posterior  part  of  the 
cervix  near  the  vaginal  attachment  is  a  well  defined  adenomyoma  2.5  by  2  cm.  For  the 
histologic  picture,  see  Figure  23. 

out  like  the  broad  roots  of  a  tree.  It  also  encroaches  slightly  on  the  posterior 
vaginal  wall.  The  mucosa  of  the  vaginal  portion  of  the  cervix  is  somewhat 
everted.  The  mucous  membrane  lining  the  cervical  canal  and  the  cavity  of  the 
uterus  presents  the  usual  appearance. 

On  account  of  mutilation  it  is  impossible  to  tell  which  are  the  right  and 
which  the  left  appendages.  One  ovary  has  been  converted  into  a  thin-walled 
cyst,  7  cm.  in  diameter.  The  inner  surface  of  this  presents  a  dirty  chocolate- 
colored  appearance.  It  is  a  corpus  luteum  cyst.  A  .portion  of  the  other  ovary 
is  covered  by  dense  adhesions.  It  contains  a  corpus  luteum  cyst,  4  cm.  in 
diameter.  Accompanying  the  specimen  is  one  fallopian  tube  which  is  perfectly 
normal.     As  noted  from  the  history,  one  tube  and  part  of  one  ovary  were  left 


32 


33 

in  place.     We  had   in  this   case   corpora   lutea  cysts   on  both   sides,   and  these 
were  covered  by  adhesions  while  both  tubes  were  normal. 

The  appendix  is  very  hard,  9  mm.  in  diameter.  The  lumen  of  the  appendix 
is  not  over  1  mm.  in  diameter. 

Hisfoloffic  Examhuition. ~Tht  cervical  glands  present  the  usual  appearance. 
The  mucosa  lining  the  body  of  the  uterus  shows  some  small  round  cell  infiltra- 
tion in  the  superficial  layers.  The  growth  on  the  posterior  surface  of  the 
cervix  consists  of  nonstriped  muscle  and  fibrous  tissue.  Scattered  throughout 
it  are  large  and  small  islands  of  uterine  mucosa  (Fig.  23).  The  stroma  of 
this  mucosa  shows  a  considerable  amount  of  hemorrhage.  Here  and  there  a 
uterine  gland  lies   in  direct  contact  with  the  muscle. 

The   picture   is   that  of  a   typical   adenomyoma   of   the   rectovaginal   septum. 


Mvoina 


Adenomyoma 


Fi&-  24  (Case  8;. — Multiple  uterine  myomas;  adenomyoma  of  the  rec.ovaginal  septum. 
The  specimen  is  viewed  from  behind.  Scattered  over  the  posterior  surface  of  the  uterus  are 
several  small  myomas,  and  projecting  into  the  left  broad  ligament  is  a  mvoma  3.5  bv  2.5  cm. 
Occupying  the  posterior  part  of  the  cervix  is  a  rather  extensive  aden'omvoma.  This  was 
densely  adherent  to  the  rectum  which  had  been  drawn  up.  For  the  histologic  appearance 
of  the  adenomyoma,  see  Figure  25. 


Case  8  (Septum  Case  16). — Adenomyoma  of  the  rectovaginal  septum;  small 
multiple  titerine  myomas  (Figs.  24  and  25). 

History  (C.  H.  I.  No.  22465).— C.  W.,  aged  2,6.  was  referred  to  me  by  Dr. 
Carlton  M.  Cook,  Oct.  9,  1919. 

She  began  to  menstruate  at  14,  was  regular;  the  flow  was  free  and  lasted 
from  six  to  seven  days.  It  was  formerly  painful  for  the  first  two  days  but 
now  the  pain  persisted  throughout  the  entire  period  and  the  patient  had  to 
remain  in  bed.  Her  last  period  ended  a  few  days  ago.  It  had  persisted  for 
ten  days. 

Twelve  years  ago  she  had  an  abdominal  operation ;  several  fibroids  were 
removed,  one  ovary  and  part  of  the  other  were  also  taken  away. 


34 

The  patient  has  been  worse  since  she  had  influenza  in  October,  1918. 

Examination. — The  patient  was  admitted  to  the  Church  Home  and  Infirmary 
October  9,  and  operated  on  Nov.  4,  1919.  On  examining  this  patient  under 
anesthesia,  I  felt  a  nodule,  about  1  cm.  in  diameter,  just  posterior  to  the  cervix 
and  was  instantly  reminded  of  an  adenomyoma  of  the  rectovaginal  septum. 
On  the  left  side  was  an  area  of  thickening,  approximately  2  by  3  cm.  As 
there  were  evidently  many  adhesions,  a  definite  diagnosis  could  not  be  made. 

Operation  and  Result. — I  made  a  median  incision  and  found  a  few  omental 
adhesions  on  the  anterior  abdominal  wall.  The  left  tube  and  ovary  had  been 
removed  at  a  previous  operation.  The  right  ovary  was  densely  adherent  to 
the  pelvic  floor  and  also  to  an  epiploic  appendage.  We  decided  that  a  removal 
of  the  uterus  was  indicated,  more  particularly  as  the  cervix  was  adherent  to 
the  anterior  surface  of  the  rectum.  The  rectum  was  also  drawn  upward.  We 
removed  the  uterus  from  left  to  right,  amputating  through  the  cervix  and 
removing  the  left  tube  and  ovary. 


Fig.  25  (Case  8). — Adenomyoma  of  the  rectovaginal  septum.  For  the  gross  picture,  see 
Figure  24.  The  muscular  growth  is  very  dense,  the  glands  few  and  far  between.  In  the 
upper  part  of  the  picture  is  a  definite  gland  lying  in  direct  contact  with  the  muscle,  and  the 
surface  at  a  is  covered  by  one  layer  of  cylindric  epithelium. 

After  removing  the  uterus,  I  took  out  the  cervix  and  it  was  necessary  lit- 
erally to  cut  the  posterior  vaginal  wall  and  the  cervix  away  from  the  rectum. 
There  was  just  the  slightest  area  of  thickening  on  the  anterior  rectal  wall. 

After  controlling  all  oozing,  we  examined  the  right  ureter  and  found  it  nor- 
mal. The  left  ureter  could  not  have  been  located  without  a  great  deal  of  dis- 
secting. The  appendix  was  curled  on  itself  and  adherent.  It  was  also  removed. 
Two  drains  were  left  in  the  pelvis  and  brought  out  through  the  vagina. 

The  patient  left  the  hospital  in  excellent  condition  on  Nov.  24,  1919. 

Examination  of  Specimen  (Gyn.  Path.  No.  25477). — The  cervix  and  body 
of  the  uterus  when  put  together  give  a  combined  length  of  8  cm.  (Fig.  24). 
The  uterus  is  6  cm.  broad  and  4  cm.  in  its  anteroposterior  diameters.  The 
anterior  surface  of  the  uterus  is  smooth,  but  nearly  the  entire  posterior  sur- 
face is  covered  by  adhesions.  Projecting  from  the  posterior  surface,  high  up, 
is  a  pedunculated  bean-shaped  myoma,  1.5  cm.  long.  There  are  also  a  few 
other  minute  myomas  scattered  over  the  surface  of  the  uterus.  Attached  to 
the  left  side  of  the  cervix  and  extending  into  the  broad  ligament  is  a  myoma. 


3.5  by  2.5  cm.  Projecting  from  the  center  of  the  cervix  posteriorly  is  a  small 
raised  area  of  thickening,  about  1  cm.  in  diameter.  This  is  where  the  rectum 
was  attached  to  the  cervix.  The  cavity  of  the  uterus  contains  a  pedunculated 
submucous  myoma,  2  cm.  in  diameter.  The  thickening  noted  on  the  posterior 
wall  of  the  cervix  is  hard  and  contains  a  few  chocolate-colored  areas. 

Histologic  Examination. — Sections  from  the  cervix  show  that  the  mucosa 
is  normal.  The  growth  on  the  posterior  surface  of  the  cervix  consists  of  non- 
striped  muscle  and  tibrous  tissue.     In  the  outlying  portions  it  is  interesting  to 


Fig.  26  (Case  91. — Adenomyoma  of  the  rectovaginal  septum.  The  patient  is  shown  in 
the  knee-chest  posture.  Just  behind  the  cervix  and  slightly  to  the  left  of  the  median  line 
is  a  relatively  globular  nodule  about  1.5  cm.  in  diameter.  In  this  nodule  were  two  bluish 
black  cysts,  only  one  of  which  could  be  clearly  seen.  The  relation  of  the  adenomyoma  to 
the  c«rvix  and  rectum  is  clearly  indicated  in  the  picture  to  the  right.  Althotigh  no  micro- 
scopic examination  has  been  possible,   still  the  diagnosis  is  certain. 


see  the  manner  in  which  the  diffuse  myomatous  growth  is  gradually  replacing 
the  adipose  tissue.  Here  and  there  in  the  dittuse  growtli  is  a  uterine  gland 
usually  lying  in  direct  contact  with  the  muscle  (.Fig.  25).  Soine  of  the  growth 
has.  as  was  noted  at  operation,  been  left  attached  to  the  rectum. 

Case    9     (^Septum    Case    17).  —  Adcnoinxonia    of    tlic    rectovaginal    septum 

(Fig.  ze'). 

History. — Mrs.  E.  B.  H..  aged  36.  referred  to  me  by  Dr.  Arthur  Wegefarth, 
entered   the   Church   Home   and   Infirmary   Xov.    1.    1919    (Xo.   22461\     I   had 

operated   on   this   patient   in    1917    for    appendicitis.     In   August.    1919.   while   at 


36 

dinner,  she  was  taken  with  sharp,  excruciating  pain  beneath  the  right  costal 
margin,  and  the  pain  radiated  to  a  point  just  beneath  the  right  shoulder  blade. 
She  was  almost  drawn  double.  This  attack  was  followed  by  nausea  and  vomit- 
ing, and  the  pain  was  relieved  only  by  morphin.  Since  then  she  had  had  eight 
similar  attacks.  The  patient  had  been  married  twenty  years  and  had  one  child, 
nineteen  years  ago.  She  also  complained  of  pain  in  the  left  lower  abdomen. 
Examination. — On  making  a  pelvic  examination,  under  anesthesia,  I  found 
the  uterus  normal  in  size.  The  cervix  was  normal,  but  just  posterior  and  a 
little  to  the  left  was  a  rather  globular  nodule  1.5  cm.  in  diameter  (Fig.  26). 
This  seemed  fixed  to  the  cervix  posteriorly,  and  on  inspection  it  was  found 
that  projecting  from  the  vaginal  vault  at  this  point  were  two  bluish  black 
cysts,  about  2  mm.  in  diameter.  On  rectal  examination,  the  nodule  was  made 
out  much  more  clearly.  It  was  directly  beneath  the  mucous  membrane,  but 
the  mucosa  had  not  become  adherent.     It  was  a  definite  adenomyoma. 


Adeno  myoma 


/agina 


Adeno  myoma  pressing 
on  ureter 


Fig.  27  (Case  10). — Adenomyoma  of  the  rectovaginal  septum;  discrete  and  independent 
adenomyoma  in  the  right  broad  ligament  pressing  on  and  partially  obstructing  the  ureter. 
Springing  from  the  top  of  the  uterus  is  a  small  myoma,  and  attached  to  the  posterior  sur- 
face of  the  uterus  are  a  few  adhesions.  Occupying  the  posterior  part  of  the  cervix  and 
extending  upward  is  a  diffuse  adenomyoma.  The  right  tube  and  ovary  are  normal.  The  left 
tube  is  normal,  but  the  ovary  contains  a  corpus  luteum  cyst.  In  the  right  broad  ligament  is 
a  small  discrete  nodule  pressing  on  the  right  ureter.  It  is  also  an  adenomyoma.  For  the 
histologic  picture  of  the  adenomyoma  of  the  rectovaginal  septum,  see  Figure  28;  for  that 
of  the  broad  ligament  nodule,  Figure  29. 


Operation  and  Result. — Nov.  4,  1919,  I  operated  and  as  the  patient  was  not 
complaining  sufficiently  of  the  pelvic  condition,  and  as  she  had  gallstones,  I 
let  the  adenomyoma  alone.  I  made  a  right  rectus  incision  and  exposed  the 
gallbladder  which  contained  a  large  number  of  small  stones,  the  greater  num- 
ber of  which  formed  two  conglomerate  masses,  each  about  1.5  cm.  in  diameter. 
Some  of  the  smaller  stones  were  in  the  cystic  duct.     We  removed  the  stones 


Z7 

and  drained  the  gallbladder.  The  patient  was  discharged  much  relieved, 
Nov.  29,  1919. 

A  few  weeks  later  she  developed  a  pelvic  abscess  which  opened  spontane- 
ously into  the  vagina,  and  since  then  she  has  been  perfectly  comfortable.  It 
may  be  necessary  to  remove  the  adenomyoma  at  a  later  date. 

Case  10  (Septum  Case  18). — -Adenomyoma  of  the  rectovaginal  septum;  dis- 
crete adenomyoma  in  the  right  broad  ligament  pressing  on  and  partially  obstruct- 
ing the  right  ureter  (Figs.  27,  28  and  29). 

History. — Miss  R.  M.,  aged  42,  was  referred  to  me  by  Dr.  Christian  Deetjen 
on  Feb.  27,  1919,  com,plaining  of  pain  in  the  left  lower  abdomen.  This  had 
been  more  or  less  constant  for  the  last  ten  years  and  had  been  severe  for  four 
years.  The  patient  had  pneumonia  ten  years  ago  followed  by  empyema.  She 
was  admitted  to  the  Church   Home  and  Infirmary,  Oct.  20,   1919    (No.  22402). 


Fig.  28  (Case  10). — Adenomyoma  of  the  rectovaginal  septum.  The  gross  specimen  is 
shown  in  Figure  27.  Some  of  the  glands  are  surrounded  by  the  characteristic  stroma,  others 
lie  in  direct  contact  with  the  muscle. 


At  that  time  a  small  cyst  could  be  felt  in  the  left  side  of  the  pelvis.  Dr. 
Hiram  Fried,  the  resident,  felt  that  there  might  be  some  trouble  with  the  ureters 
and  suggested  their  catheterization.  A  distinct  narrowing  was  felt  on  the 
right  side  not  far  distant  from  the  bladder.  Dr.  Guy  L.  Hunner  confirmed 
this  finding.  The  right  ureter  was  dilated  on  several  occasions,  and  we  finally 
operated  on  November  8. 

Operation  and  Result. — On  opening  the  abdomen,  I  found  a  corpus  luteum 
cyst,  4  cm.  in  diameter,  on  the  left  side.     This  was  somewhat  adherent. 

The  rectum  had  grown  fast  to  the  posterior  surface  of  the  cervix  and  at 
this  point  the  tissues  presented  a  yellowish  brown,  rusty  appearance.  It  was 
perfectly  evident  that  we  were  dealing  with  an  adenomyoma.     We  performed 


38 


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39 

a  complete  abdominal  hysterectomy.  The  posterior  vaginal  wall  separated  from 
the  rectum  with  some  difficulty,  but  after  removal  of  the  uterus  and  upper 
vagina  the  bowel  showed  only  a  slight  thickening.  The  rectovaginal  growth 
had  extended  out  into  the  right  broad  ligament.  After  its  removal  we  could 
still  feel  a  nodule  far  out  in  the  broad  ligament.  This  was  1  cm.  in  diameter, 
encroached  markedly  on  the  right  ureter  and  had  given  rise  to  the  obstruction 
that  had  been  noted  by  Dr.  Fried  in  his  catheterization  of  this  ureter  (Fig.  27). 
I  dissected  out  the  ureter,  drew  it  to  one  side  and  removed  the  nodule.  Two 
drains  were  left  in  the  pelvis  and  brought  out  through  the  vagina. 

The  patient  had  an  uneventful  convalescence  and  was  discharged  Nov. 
30,  1919. 

Examination  of  Specimen  (Gyn.  Path.  No.  25486). — The  uterus  is  7  cm. 
long,  4  cm.  broad  and  3  cm.  in  its  anteroposterior  diameter.  Anteriorly  it  is 
smooth.  The  posterior  surface  is  covered  by  adhesions.  At  the  fundus  pos- 
teriorly is  a  myoma,  1.5  cm.  in  diameter,  and  below  this  a  minute  myoma. 
Springing  from  the  posterior  surface  of  the  cervix,  is  a  nodular  thickening, 
1.5  cm.  in  diameter,  and  extending  off  from  this  point  is  the  nodule  that  was 
pressing  on  the  right  ureter.  The  uterine  walls  vary  from  1  to  1.5  cm.  in  thick- 
ness, and  in  the  fundus  the  muscle  presents  a  very  coarsely  striated  appearance 
reminding  one  somewhat  of  an  adenomyoma.    The  uterine  mucosa  is  rather  thin. 

Right  Side :     The  tube  and  ovary  are  normal. 

Left  Side :  The  ovary  contains  a  corpus  luteum  cyst,  3  cm.  in  diameter. 
The  ovary  is  covered  by  a  few  adhesions. 

Histologic  Examination. — The  vaginal  portion  of  the  cervix  presents  the 
usual  appearance.  The  cervical  mucosa  is  gathered  into  folds  and  tends  to 
form  small  polypi.  A  few  of  the  glands  are  dilated,  but  the  cervical  mucosa 
as  a  whole  is  relatively  normal. 

The  section  from  the  growth  on  the  posterior  surface  of  the  cervix  con- 
tains a  young  myoma,  3  mm.  in  diameter.  The  diffuse  growth  consists  of 
nonstriped  muscle  and  fibrous  tissue.  Scattered  throughout  it  are  small  areas 
of  uterine  mucosa  (Fig.  28).  Few  of  these  areas  contain  more  than  two 
uterine  glands  accompanied  by  the  characteristic  stroma.  Here  and  there  is 
a  dilated  gland. 

The  nodule  from  the  right  broad  ligament,  the  one  that  was  pressing  on  the 
right  ureter,  consists  for  the  most  part  of  adipose  tissue  (Fig.  29).  Scattered 
throughout  the  fat  are  a  good  many  large  blood  vessels  and  passing  off  from 
these  are  young  strands  of  connective  tissue  which  tend  to  separate  the  indi- 
vidual fat  globules  from  one  another.  The  outer  end  of  the  growth  consists 
of  an  irregular  mass  of  fibrous  tissue  and  nonstriped  muscle.  This  fibromus- 
cular  mass  sends  prolongations  into  the  surrounding  fat  and  in  the  nodule 
itself  some  fat  still  persists.  Scattered  throughout  the  muscular  tissue  are 
uterine  glands  occurring  singly  or  in  groups.  When  in  groups,  they  are  sur- 
rounded by  the  characteristic  stroma  which  shows  some  hemorrhage.  When 
singly,  they  lie  in  direct  contact  with  the  muscle.  Some  of  the  glands  are 
dilated. 

This  is  a  ca^e  of  adenomyoma  of  the  rectovaginal  septum.  There  is  also 
a  discrete  adenomyoma  apparently  independent  of  the  uterus  and  pressing  on 
the  right  ureter. 

The  preceding  cases  have  come  under  my  individual  care.  The 
following  case  of  adenomyoma  of  the  rectovaginal  septum  is  a  rather 
advanced  one  and  is  well  worth  recording.     The  operation  was  per- 


40 

formed  at  the  Hebrew  Hospital  by  Dr.  Alfred  Ullman,  and  the  speci- 
men was  sent  to  me  for  examination.  The  history  was  furnished  me 
by  Dr.  E.  H.  Teeter. 

Case  11. — Adenomyoma   of  the  rectovaginal  septum. 

History. — M.  H.,  aged  46,  was  admitted  to  the  Hebrew  Hospital,  April  24, 
1919,  complained  of  bleeding  for  nine  weeks,  and  that  she  felt  very  sore  and 
tired  all  over.  She  had  not  had  any  previous  illness.  Her  menses  began  at 
13,  were  regular,  and  usually  lasted  from  seven  to  nine  days.  The  flow  was 
always  excessive  and  was  accom,panied  by  pain  in  the  left  lower  abdomen  for 
three  days.  In  June,  1918,  her  menses  stopped  for  three  months  and  then  there 
was  a  little  bleeding  for  a  couple  of  days.  The  bleeding  soon  returned  and 
had  persisted   for  the  last  nine  weeks.     It  had  been   very   severe.     On  vaginal 


Libe 


Adenomyoma 
of  left  round  ligament 


Myoma 


Fig.  30  (Case  12). — Adenomyoma  of  the  left  round  ligament.  The  uterus  contains  several 
small  discrete  myomas.  The  left  round  ligament  near  its  uterine  attachment  contains  a 
spherical  myoma,  1.5  cm.  in  diameter.  This  was  adherent  to  the  tube  at  its  inner  end. 
Lying  between  the  round  ligament  nodule  and  the  tube  and  adherent  to  both  was  a  loop  of 
small  bowel.  The  left  tube  is  unusually  thick.  Its  fimbriated  end  is  constricted  but  open. 
The  tube  on  histologic  examination  showed  slight  inflammation.  The  ovary  contained  a 
corpus  luteum.  It  was  slightly  adherent.  For  the  low  power  picture  of  the  adenomyoma 
of  the   round  ligament,   see   Figure   31;   for  the   higher  power,    Figure    32. 

examination,  April  25,  Dr.  Teeter  made  the  following  note :  "Vaginal  outlet 
somewhat  relaxed,  cervix  normal.  The  uterus  and  cervix  are  tied  hard  and 
fast  and  cannot  be  moved.  The  uterus  itself  is  normal  in  size.*  Just  posterior 
to  the  cervix  is  a  growth  in  the  vaginal  vault  causing  puckering  of  the  vaginal 
mucosa.  This  growth  is  hard  and  is  glued  fast  to  the  rectum.  On  rectal 
examination,  the  mass  is  found  to  be  adherent  to  the  rectum,  but  the  growth 
does  not  involve  the  rectal  mucosa." 

There  was  a  profuse  bloody  discharge  from  the  uterus  and  Dr.  Teeter  at 
once  made  a  diagnosis   of  adenomyoma  of  the  rectovaginal  septum. 


41 

A  complete  abdominal  hysterectomj^  was  performed  by  Dr.  Alfred  Ullman 
on  April  26,  and  the  patient  was  discharged  May  20. 

Examination  of  Specimen  (Gyn.  Path.  Xo.  25513). — The  uterus  is  9  cm. 
long,  6  cm.  broad  and  5  cm.  in  its  anteroposterior  diameters.  The  anterior 
surface  is  smooth  as  is  also  the  posterior  surface.  Just  anterior  to  the  insertion 
of  the  right  tube  is  a  myoma,  6  mm.  in  diameter  . 

Springing  from  the  posterior  surface  of  the  cervix  and  extending  over  to 
the  right  side  and  also  involving  the  posterior  vaginal  wall  is  a  hard,  irregular 


^ 


\  " 


Fig.  31  (Case  12). — Adenomyoma  of  the  round  ligament.  This  is  a  low  power  photo- 
micrograph of  the  round  ligament  nodule  seen  in  Figure  30.  Nearly  one  half  of  the  tissue 
consists  of  islands  of   perfectly  normal   uterine   mucosa.      For   the   high   power,   see   Figure   32. 


growth,  4.5  cm.  broad  and  2.5  cm.  from  above  downward.  It  is  exceedingly 
firm  and  where  it  involves  the  vagina  are  five  or  six  dark  brown  areas  of 
discoloration.  These  vary  from  1  to  2  mm.  in  diameter.  On  section,  the  growth 
reminds  one  of  myomatous  tissue,  and  scattered  throughout  it  are  a  few  irregu- 
lar cavities  filled  with  a  yellowish  brown  or  yellow  material.  The  cavity  of 
the  uterus   looks  normal. 


42 

Histologic  Examination. — Sections  through  the  vaginal  portion  of  the  cervix 
and  also  through  the  adjoining  vaginal  wall  reveal  a  normal  mucosa.  Beneath 
the  vaginal  mucosa  the  dense  stroma  contains  isolated  uterine  glands.  The 
small  chocolate-colored  cysts  noted  beneath  the  vaginal  mucosa  are  filled  with 
blood.  They  are  lined  with  one  layer  of  cylindric  epithelium,  and  projecting 
into  one  of  the  cysts  is  a  small  knoblike  elevation  of  typical  stroma  of  the 
endometrium  of  the  body  of  the  uterus.  Some  of  these  cj'sts  lie  in  direct 
contact  with  the  surrounding  muscular  and  fibrous  tissue,  others  are  separated 
by  a  definite  endometrial  stroma. 

The  growth  on  the  posterior  surface  of  the  cervix  and  involving  the  pos- 
terior vaginal  wall  consists  of  nonstriped  muscle  and  fibrous  tissue.  Here 
and  there  small  areas  of  adipose  tissue  have  been  enveloped.  Scattered 
throughout  the  growth  are  isolated  uterine  glands  and  groups  of  glands.  Nearly 
all  of  these  glands  are  surrounded  by  the  characteristic  stroma,  and  some  of 
them  are  filled  with  blood. 

The  case  is  one  of  adenomyoma  of  the  rectovaginal  septum.  It  is  in  just 
such  a  case  that  we  would  later  expect  to  find  vaginal  polypi  had  the  opera- 
tion been  delayed  for  a  year  or  two. 

ADEXOMYOMA    OF     THE     UTERINE     HORN     OR     FALLOPIAN     TUBE 

In  addition  to  the  diffuse  adenomyoma  of  the  uterus,  one  finds 
another  variety  of  adenomyoma  in  this  organ.  These  are  the  small 
adenomyomatous  nodules  noted  in  one  or  both  uterine  horns.  They 
vary  from  a  few  millimeters  to  about  2  cm.  in  size  and  are  often  asso- 
ciated with  an  old  inflammatory  process  in  the  tubes.  These  growths 
usually  contain  many  isolated  glands  embedded  in  nonstriped  muscle 
and  inflammatory  tissue.  The  glands  usually  lie  in  direct  contact  with 
the  muscle  and  are  devoid  of  the  characteristic  stroma.  Adenomyoma 
of  the  uterine  horn  can,  as  a  rule,  hardly  be  looked  on  as  a  distinct 
clinical  entity,  but  rather,  I  think,  as  part  of  the  end-result  of  a  mild 
inflammatory  process. 

In  a  case  (Gyn.-Path.  No.  25515)  in  which  we  had  a  bicornate 
uterus,  and  a  most  extensive  adenomyoma  of  the  right  cornu,  the  left 
tube  2  cm.  beyond  the  uterine  horn  was  1  cm.  in  diameter.  On  his- 
tologic examination,  it  was  found  to  be  the  seat  of  an  adenomyoma. 
Some'  of  the  glands  lay  in  direct  contact  with  the  muscle,  others  were 
surrounded  by  the  typical  stroma  of  the  uterine  mucosa.  I  know  of  no 
other  tube  presenting  such  a  picture. 

ADENOMYOMA     OF    THE     ROUND    LIGAMENT  * 

In  1896,  it  fell  to  my  lot  to  record  the  first  growth  of  this  character. 
Since  then  quite  a  number  have  been  noted.  Somewhere  along  the 
course  of  the  round  ligament,  usually  near  the  external  ring,  a  nodule 


4.  Cullen,  T.  S. :  Adenomyoma  of  the  Round  Ligament,  Bull.  Johns  Hop- 
kins Hosp.  7:112  (May- June)  1896;  Further  Remarks  on  Adenomj-oma  of  the 
Round  Ligament,  Bull.  Johns  Hopkins  Hos.p.  9:142  (June)  1898;  Adenomyoma 
of  the  Round  Ligament,  and  Incarcerated  Omentum  in  an  Inguinal  Hernia, 
Together  Forming  One  Tumor,  Surg.,  Gynec.  &  Obst.  22:258  (March)  1916. 


43 

one  or  more  centimeters  in  diameter  is  detected.  On  going  carefully 
into  the  history,  it  will  be  noted  that  this  growth  swells  perceptibly  at 
the  period.  One  patient  was  sent  to  me  on  the  assumption  that  a 
hernia  existed,  but  even  in  this  case  in  the  history  it  was  recorded  that 
the  swelling  was  more  painful  and  more  prominent  at  the  period. 

With  the  gradual  increase  in  size  of  the  nodule  it  may  become 
intimately  blended  with  the  fascia.  In  my  second  case  the  diagnosis 
was  easily  confirmed  at  operation,  even  before  any  microscopic  exam- 
ination had  been  made.  The  surrounding  fascia  had  imbibed  a  large 
amount  of  golden  yellow  pigment — the  remnant  of  old  menstrual  blood. 

Some  of  these  growths  can  be  removed  very  readily,  others,  how- 
ever, in  time  may  become  so  intimately  blended  with  the  surrounding 
structures  that  they  must  be  literally  cut  away.  On  histologic  examina- 
tion, they  are  found  to  be  made  up  of  nonstriped  muscle,  fibrous  tissue, 
and  the  characteristic  uterine  glands.  Strands  of  fibrous  tissue  and 
nonstriped  muscle  spread  out  into  the  surrounding  adipose  tissue.. 

Just  lately  (April,  1920)  we  have  encountered  another  case  of 
adenomyoma  of  the  round  ligament  in  our  clinic  in  the  Johns  Hopkins 
Hospital  (Fig.  30). 

Case  12  (Gyn.  No.  25776). — -History. — E.  S.,  aged  36,  white,  was  admitted 
to  the  Johns  Hopkins  Hospital  on  April  1,  1920,  complaining  of  dysmenorrhea 
and  of  bleeding  between  periods.  She  had  been  married  four  years,  but  had 
had  no  children. 

Examination. — On  pelvic  examination,  the  outlet  was  found  to  be  relatively 
intact.  Protruding  from  the  cervix  was  a  small  polyp.  The  body  of  the  uterus 
was  in  retroposition,  was  irregular  and  apparently  contained  five  or  six  small 
myomatous  nodules.  High  up  in  the  left  vaginal  fornix  was  a  mass,  2  or  3  cm. 
in  diameter. 

Operation  and  Result. — April  3,  1920,  Dr.  Leo  Brady  operated  and  found 
the  uterus  in  retroposition.  It  contained  several  small  myomas.  In  the  left 
round  ligament  near  the  uterus  was  a  nodule  nearly  2  cm.  in  diameter.  The 
tube  was  adherent  to  this  and  also  to  a  loop  of  small  bowel.  The  right  appen- 
dages were  free.  After  the  loop  of  bowel  had  been  freed,  a  supravaginal 
hysterectomy  was  performed.  The  patient  made  a  satisfactory  recovery  except 
for  a  slight  elevation  of  temperature  during  the  first  week  following  operation 
when  there  was  a  friction  rub.  This  was  thought  to  be  due  probably  to  a 
lighting  up  of  an  old  pleurisy.  She  was  discharged  in  good  condition  on  April 
21,   1920. 

Examination  of  Specimen  (Gyn.  Path.  Xo.  25850). — The  uterus,  which  had 
been  amputated  through  the  cervix,  measures  5  cm.  in  length,  5  cm.  in  breadth 
and  4  cm.  in  its  anteroposterior  diameters.  It  contains  several  interstitial 
myomas.  In  the  left  round  ligament  near  the  uterus  is  a  spherical  nodule 
1.5  cm.  in  diameter  (Fig.  30).  This  is  partly  covered  by  adhesions.  The  left 
tube  reaches  a  diameter  of  1  cm.  Its  fimbriated  end  is  constricted  but  open. 
The  OA^-ary  is  normal  in  size.  It  contains  a  corpus  luteum  and  is  partly  covered 
by  adhesions. 

Histologic  Examination-. — This  shows  that  the  nodule  in  the  left  round  liga- 
ment is  riddled  with  large  islands  of  typical  uterine  mucosa   (Figs.  31  and  32). 


44 


UTERINE    MUCOSA    IN    THE    OVARY 


In  1898  my  colleague,  Dr.  William  Wood  Russell,  reported  a  case 
in  which  the  ovary,  although  showing  little  increase  in  size,  contained 
large  islands  of  uterine  mucosa.    The  report  of  this  case  was  published 


Fig.  32  (Case  12). — Adenomyoraa  of  the  round  ligament.  For  the  gross  appearance,  see 
Figure  30,  and  for  the  low  power  picture,  Figure  31.  The  round  ligament  nodule  consists 
of  myomatous  tissue.     It  contains   large   quantities   of   normal   uterine  mucosa. 

in  detail  in  the  Bulletin  of  Johns  Hopkins  Hospital  for  that  year,  and 
the  article  is  freely  illustrated. 

Within  the  last  year  Dr.  Charles  Norris  of  Philadelphia  sent  me  a 
section  of  a  relatively  small  ovary  containing  a  large  island  of  normal 
uterine  mucosa  (Figs.  ZZ  and  34). 


45 

Dr.  DeWitt  B.  Casler,  of  our  department,  at  the  1919  meeting  of  the 
American  Gynecological  Society  reported  a  unique  case  which  has  a 
definite  bearing  on  this  subject. 

The  patient,  a  trained  nurse,  38  years  of  age,  had  had  excessive  periods 
for  one  year.  On  examination  the  uterus  was  found  to  be  three  times  its 
usual  size.  Hysterectomy  was  performed.  The  increase  in  size  was  due  ta 
a  diffuse  myomatous  thickening,  and  scattered  throughout  this  diffuse  growth 
were  quantities  of  stroma  identical  with  that  of  the  uterine  mucosa.  This 
stroma,  however,  contained  no  glands.  The  tumor  resembled  in  every  par- 
ticular the  picture  of  an  ordinary  adenomyoma  of  the  uterus  save  for  the  fact 
that  the  glands  were  missing  from  the  stroma. 


Fig.  33. — An  ovary  containing  uterine  mucosa.  This  is  a  very  low  power  photomicrograph 
of  a  section  through  an  entire  ovary  that  was  little  enlarged.  It  was  sent  me  by  Dr. 
Charles  Norris  of  Philadelphia.  On  the  left  is  a  relatively  small  cyst,  c.  At  a  in  the  sub- 
stance of  the  ovary  is  a  large  area  of  typical  uterine  mucosa.  This  is  connected  with  an 
irregular  cyst  cavity.  On  the  upper  edge  of  the  section  is  normal  tubal  mucosa,  b.  The 
tubes  have  evidently  been  intimately  adherent  to  the  ovary.  In  Figure  34  one  sees  a 
higher  magnification   of  the  mucosa. 

This  patient  after  the  complete  hysterectomy  still  continued  to  menstruate 
regularly  through  the  vaginal  vault.  A  vaginal  examination  about  three  and 
one-half  years  after  the  hysterectomy  revealed  the  fact  that  the  ovary  which 
had  been  left  was  perfectly  normal  in  size.  A  little  later  it  commenced  to 
grow  larger  and  when  the  abdomen  was  opened  four  years  after  the  hyster- 
ectomy, this  ovary  was  the  size  of  a  medium-sized  grape  fruit. 

On  histologic  examination  great  quantities  of  typical  uterine  mucosa  were 
found  scattered  throughout  the  ovarian  tumor,  thus  clearly  explaining  why  the 


46 

patient  had  continued  to  menstruate  without  any  uterus.  The  ovary  contained 
all  the  essential  elements,  normal  ova,  and  practically  normal  uterine  mucosa, 
and  the  small  tract  left  where  the  uterus  had  been  removed  supplied  the  neces- 
sary avenue  along  which  the  menstrual  flow  esca,ped. 

In  the  following  case,  in  which  the  uterus  was  about  three  times 
enlarged  as  a  result  of  interstitial  and  submucous  myomas  and  in  which 
the  appendages  were  glued  together  by  adhesions,  the  right  ovary  con- 
tained small  areas  of  typical  uterine  mucosa. 


Fig.  34. — Uterine  mucosa  in  the  ovary.  This  specimen  was  sent  me  by  Dr.  Charles  Norris 
of  Philadelphia.  For  the  low  power  picture,  see  Figure  33.  The  area  of  mucosa  is  sharply 
defined  and  consists  of  typical  uterine  mucosa  embedded  in  the  substance   of  the  ovary. 

Case  13. — A  myomatous  uterus  with  adherent  appendages  on  the  right  side, 
and  on  the  left  a  small  ovarian  cyst  containing  uterine  mucosa  in  its  walls 
(Figs.  35  and  36). 

Examination  of  Specimen  (Gyn.  Path.  No.  22505,  Sept.  19,  1916).— The  speci- 
men consists  of  the  supravaginally  amputated  myomatous  uterus  together  with 
the  appendages    (Fig.  35). 

The  portion  of  the  uterus  present  is  10  cm.  long,  10  cm.  broad  and  10  cm. 
in  its  anteroposterior  diameter.  At  the  fundus  anteriorly  are  a  few  omental 
adhesions.  Occupying  the  posterior  wall  of  the  uterus  is  a  myoma  8  cm.  in 
diameter.      Scattered    throughout    the   anterior    wall    are    several    nodules,    the 


47 


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a  to 
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0)  c] 


o  <u 

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s.s 

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1.^ 


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48 

largest  3  cm.  in  diameter.  Projecting  into  and  filling  the  cavitj-  of  the  uterus 
is  a  myoma,  4  cm.  long  and  2.5  cm.  broad. 

Right  Side:  The  tube  is  8  cm.  in  length  and  varies  from  8  to  10  mm.  in 
diameter.  Its  fimbriated  end  is  free.  The  ovary  is  7  cm.  in  length.  It 
reaches  a  thickness  of  2.5  cm.  Attached  to  the  outer  end  is  a  moderate  amount 
of  fat.  This  appears  to  be  omental  in  character.  In  the  lower  end  of  the 
ovary  is  what  appears  to  be  a  collapsed  corpus  luteum  cyst.  It  is  about  4  cm. 
in  length. 

Left  Side:  The  tube  is  11  cm.  long.  At  the  cornu,  it  is  1.3  cm.  in  diameter. 
In  its  middle  portion,  it  is  a  little  smaller,  but  in  its  distal  5  cm.  it  varies 
from  2  to  2.5  cm.  in  diameter.  Where  dilated  it  has  thin  walls,  a  brownish 
inner  surface  and  apparently  contains  old  blood.  Its  fimbriated  end  is  closed 
and  between  the  closed  end  and  the  ovary,  omental  fat  has  become  densely 
adherent.  The  ovary  is  6  cm.  long  and  varies  from  2  to  3  cm.  in  thickness. 
It  is  covered  by  adhesions. 

Histologic  Examination. — It  is  difficult  to  get  the  exact  relationship  on 
account  of  the  ragged  condition  of  the  specimen,  but  on  microscopic  exam- 
ination of  the  left  ovarian  cyst,  which  was  lined  with  a  brownish  membrane. 
it  is  seen  that  the  cyst  has  an  inner  lining  of  cylindric  epithelium  which  here 
and  there  tends  to  form  folds.  At  some  points  beneath  the  epithelium  there  is 
a  definite  stroma  and  embedded  in  this  are  a  few  glands  (Fig.  36).  The  cyst 
is  partially  filled  with  blood. 

In  a  case  (Gyn.-Path.  No.  25003)  in  which  the  uterus  was  13  by 
11  cm.,  the  enlargement  was  due  to  a  submucous  myoma.  On  the 
posterior  surface  of  the  cervix  and  lower  part  of  the  body  of  the 
uterus  was  the  most  widespread  adenomyoma  of  the  rectovaginal 
septum  that  I  have  even  seen  (Fig.  16).  I  had  literally  to  cut  the 
cervix  away  from  the  rectum. 

On  the  surface  of,  and  intimately  attached  to,  the  right  ovary  was 
a  miniature  uterine  cavity  (Fig.  21).  The  glands  in  this  showed  a 
moderate  hypertrophy.  Other  sections  from  the  same  ovary  showed 
a  diffuse  adenomyoma  intimately  blended  with  the  ovarian  tissue,  so 
intimately  that  no  line  of  demarcation  could  be  detected.  It  must  be 
remembered,  however,  that  this  ovary  was  firmly  glued  to  and  con- 
tinuous with  the  diffuse  adenomyoma  that  occupied  the  posterior  sur- 
face af-'the  uterus.  It  is  quite  possible  that  the  uterine  mucosa  on  the 
surface  of  this  ovary  was  due  to  an  overflow  of  the  adenomyoma  of 
the  rectovaginal  septum. 

On  Oct.  25,  1919,  I  received  a  very  interesting  letter  from  Dr. 
Otto  Schwarz  of  St.  Louis.  In  it  he  referred  at  length  to  several 
cases  of  adenomyoma  that  he  had  recently  seen.  Among  other  speci- 
mens examined  was  one  in  which  the  ovary  contained  uterine  mucosa. 
Dr.  Schwarz  said : 

The  ovarian  case  was  most  interesting;  this  ovary  was  removed  about  a 
year  and  a  half  ago.  It  was  about  the  size  of  a  hen's  egg  and  showed  nothing 
unusual  externally.  On  section  it  showed  several  cavities  which  were  filled 
with    blood,   partly   clotted.     Two   large   blocks   were   cut   transversely   across 


49 


•:.f\     •  /-•  ^  •■&». 


Fig.  36  (Case  13). — A  small  ovarian  cyst  lined  in  part  by  uterine  mucosa.  The  debris  in 
the  upper  part  of  the  picture  is  composed  chiefly  of  old  blood.  The  cyst  wall  is  lined  by 
one  layer  of  cylindric  epithelium.  In  places,  this  lies  in  direct  contact  with  the  ovarian 
tissue,  but  here  and  there  is  separated  by  a  definite  stroma.  Near  the  right,  the  stroma  is 
very  evident,  and  embedded  in  it  is  a  gland  resembling  those  of  the  body  of  the  uterus. 
For  the  gross  appearance,   see   Figure  35. 


Fig.  37. — Uterine  mucosa  lining  a  small  cyst  in  the  ovary.  The  specimen  was  sent  me  by 
Dr.  Otto  Schwarz  of  St.  Louis,  Mo.  The  cyst  wall  is  lined  with  cylindric  epithelium. 
Beneath  this  in  the  central  portion  of  the  picture  is  a  definite  mucosa  consisting  of  stroma 
and  glands  similar  to   those  found  in  the  body   of  the   uterus. 


50 

the  ovary.  ...  In  one  of  the  sections  I  enclose  the  mucosa  appears  to 
communicate  with  the  surface  but  this  is  due  to  a  tear.  Throughout  the  entire 
two  blocks,  the  abnormal  structure  was  well  within  the  ovary.  The  sections 
show  the  lesion  well  demarcated  from  the  rest  of  the  stroma  of  the  ovary. 
There  are  two  cavities.    These  are  lined  with  tissue  similar  to  the  endometrium. 

I  had  the  opportunity  of  examining  other  sections  of  the  ovary 
with  Dr.  Schwarz  in  his  laboratory  at  the  Washington  University  in 
St.  Louis  a  few  months  later.  It  is  a  beautiful  example  of  an  ovary 
containing  miniature  uterine  cavities.  Figure  Z7  is  a  photomicrograph 
that  I  have  had  made  from  one  of  Dr.  Schwarz'  sections. 


Fig.  38  (Case  14). — Cyst  of  the  right  uterosacral  ligament.  During  an  operation  for 
general  pelvic  adhesions,  the  cyst  noted  in  the  right  uterosacral  ligament  was  found.  It  was 
rather  spherical,  1.5  cm.  in  diameter,  and  was  filled  with  brownish  putty-like  material.  It 
at  once  reminded  me  of  an  adenomyoma.  Histologic  examination,  however,  failed  to  reveal 
glands  or  any  epithelial  lining  to  the  cyst. 

From  the  foregoing  it  is  evident  that  in  due  time  a  sufficient  number 
of  cases  will  undoubtedly  be  reported,  and  then  we  shall  possibly  be 
able  to  give  a  composite  picture  of  both  the  clinical  course  and  of  the 
histologic  changes  that  occur  in  this  most  unusual  group  of  cases. 

ADENOMYOMA    OF    THE     UTERQ-OVARIAN     LIGAMENT 

These  are  naturally  of  little  clinical  significance  and  will  be  recog- 
nized only  in  the  laboratory.  I  have  reported  one  case.  A  multi- 
nodular  myomatous    uterus    was    removed,    and    springing    from   the 


51 

utero-ovarian  ligament  was  a  myoma  several  centimeters  in  diameter. 
In  the  center  of  this  were  islands  of  typical  uterine  mucosa. 

(This  case  was  reported  at  length  in  my  book  on  Adenomyoma  of 
the  Uterus,  page  140,  Figs.  41  and  42.) 

ADENOMYOMA     OF    THE     UTEROSACRAL     LIGAMENT 

Several  years  ago  my  colleague,  Dr.  William  Wood  Russell, 
removed  a  pea-sized  nodule  from  the  right  uterosacral  ligament.  On 
histologic  examination  it  presented  a  typical  adenomyomatous  picture. 


Adenomyovna  of 
utero -sacral  lig'i 


Fig.  39  (Case  IS).— Adenomyoma  of  the  left  uterosacral  ligament.  On  the  posterior  sur- 
tace  ot  the  uterus  are  numerous  adhesions.  Both  ovaries  were  lightly  adherent  It  was 
possible  to  save  all  the  pelvic  structures.  In  the  left  uterosacral  ligament  is  a  well  cir- 
cumscribed spherical  nodule.  This  had  a  slightly  yellowish  brown  tinge.  For  the  histologic 
picture,  see  Figure  40.     It  was  a  typical  adenomyoma. 

Since  then  I  have  seen  a  cyst  1.5  cm.  in  diameter  apparently  spring- 
ing from  the  right  uterosacral  ligament.  It  contained  yellowish-brown 
putty-like  material.  It  may  belong  to  this  group,  but  of  this  I  cannot 
speak  with  certainty  as  the  histologic  picture  was  not  very  definite. 


52 

Case  14. — Possible  adenomyoma  of  the  right  uterosacral  ligament  (Fig.  38). 

History  (Gyn.  No.  23906). — A  B.,  aged  28,  colored,  was  admitted  to  the 
Johns  Hopkins  Hospital  on  April  5,  1918.  In  the  course  of  an  operation  for 
intestinal  and  omental  adhesions  and  bilateral  ovarian  cyst,  a  small  nodule  was 
found  in  the  right  uterosacral  ligament. 


Fig.  40  (Case  15). — Adenomyoma  of  the  left  uterosacral  ligament.  For  the  gross  appear- 
ance of  the  nodule,  see  Figure  39.  Some  of  the  glands  lie  in  direct  contact  with  the  muscle, 
others  are  surrounded  by  the  characteristic  stroma. 

Operation  and  Result. — The  midline  scar  of  a  previous  operation  was  excised. 
The  omentum  was  found  adherent  along  the  line  of  the  old  scar.  Scattered 
over  the  omentum  and  over  the  pelvic  peritoneum  were  several  small  nodules 
varying  from  2  to  3  mm.  in  diameter.  These  were  made  up  of  a  brownish, 
putty-like   material. 


53 

The  body  of  the  uterus  was  firrriily  attached  to  the  abdominal  wall  to  which 
it  had  evidently  been  sutured  at  a  former  operation.  It  was  freed.  There 
was  a  cyst  about  5  cm.  in  diameter  on  the  left  side ;  this  was  resected.  On 
the  right  side  was  a  small  cyst.     This  was  also  resected. 

A  tumor  about  1.5  cm.  in  diameter  was  seen  in  the  right  uterosacral  liga- 
ment, 3  cm.  from  the  cervix  (Fig.  38).  This  tumor  felt  rather  firm  and  was 
covered  with  peritoneum.  I  dissected  the  right  ureter  free  and  pushed  it 
outward.     The   peritoneum   over   the   tumor   was   then   opened,   and   the   tumor 


Fig.  41  fCase  16). — Adenomyoma  of  the  rectovaginal  septum.  The  neck  of  the  uterus 
has  been  drawn  strongly  forward.  Just  posterior  to  the  cervix  is  an  oval  and  slightly  raised 
area  about  2.5  by  2  cm.  The  surface  of  this  is  roughened  and  lobulated.  The  surfaces  of 
some  of  the  lobulations  are  somewhat  cystic  and  a  few  of  them  were  bluish  black,  indi- 
cating that  they  contained  old  menstrual  blood.  This  area  was  firmly  fixed  to  the  right  side 
of  the  pelvis.  For  the  abdominal  picture,  see  Figure  42,  and  for  the  histologic  picture, 
Figure  43. 


found  to  be  yellowish  red.  It  was  excised.  During  its  removal  there  was  an 
escape  of  a  light  yellow,  oily,  caseous  material.  The  peritoneum  was  brought 
together  and  the  abdomen  closed.  A  small  cigaret  drain  was  laid  in  the  lower 
angle  of  the  abdominal   incision.     The  patient  was   discharged  April  29,   1919. 


54 

Examination  of  Specimen  (Gyn.  Path.  No.  23986). — The  specimen  consists 
of  a  collapsed  cyst,  1.5  cm.  in  diameter.  This,  as  noted  at  operation,  apparently 
sprang  from  the  right  uterosacral  ligament.  It  contained  yellowish  brown, 
putty-like  material  which  escaped  during  the  operation. 

Histologic  Examination. — This  revealed  a  wall  consisting  in  large  measure 
of  fibrous  tissue.     There  was  no  trace  of  epithelium. 

Clinically,  this  case  bore  a  striking  resemblance  to  an  adenomyoma,  but 
whether  it  was  actually  an  adenomyoma  that  had  undergone  retrograde  changes, 
it  is,  of  course,  im,possible  to  determine.  We  can  think  of  nothing  else  that 
would  occasion  such  a  condition. 

On  May  20,  1919,  I  operated  on  a  patient  who  had  numerous  pelvic 
adhesions.  In  the  left  uterosacral  ligament  a  short  distance  from  the 
uterus  was  a  rounded  nodule  1.5  cm.  in  diameter.  I  isolated  the  left 
ureter  and  then  removed  the  nodule,  bringing  the  several  ends  of  the 
ligament  together  again.  This  nodule  on  histologic  examination  proved 
to  be  a  typical  adenomyoma.     The  case  is  as  follows : 

Case   15. — Adenomyoma   of  the   uterosacral   ligament    (Figs.   39   and  40). 

History. — Miss  N.  E.  T.,  aged  36,  white,  was  admitted  to  the  Church  Home 
and  Infirmary  (No.  21398)  on  May  19,  1919.  I  saw  her  in  consultation  with 
Dr.  A.  E.  Plumb  on  April  24.  Her  menses  began  at  15.  At  first,  they  were 
regular,  but  for  a  j'ear  they  had  at  times  been  a  week  ahead.  On  the  second 
day  they  were  accompanied  by  a  good  deal  of  pain.  The  last  period  had  begun 
two  weeks  before  I  saw  her. 

Two  years  ago,  she  had  an  attack  of  acute  appendicitis  and  for  six  months 
had  had  intense  pain  above  the  pubic  bone.  On  examination,  I  found  that 
she  had  a  good  deal  of  discomfort  just  above  the  symphysis  and  some  ten- 
derness in  the  appendix  region.  The  outlet  was  slightly  relaxed,  the  cervix 
was  forward,  the  body  of  the  uterus  back  on  the  bowel.  No  thickening  could 
be  made  out  on  either  side. 

Operation  and  Result. — May  20,  1919,  we  dilated  thoroughly.  On  opening 
the  abdomen,  we  found  the  bod}-  of  the  uterus  adherent  to  the  rectum.  Both 
tubes  and  ovaries  were  also  adherent.  The  adhesions  were  loosened  and  the 
fimbriated  ends  of  both  tubes  were  found  to  be  normal. 

In  the  left  uterosacral  ligament  was  a  thickening,  1.5  cm.  in  diameter 
(Fig.  39).  This  had  a  slightly  yellowish  brown  tinge.  It  strongly  suggested 
an  adenomyoma,  but  I  could  not  say  with  any  degree  of  definiteness  because 
the  ovary  was  adherent  over  it.  The  ovary,  however,  did  not  contain  any 
corpus  luteum.  After  releasing  the  adhesions,  we  dissected  out  the  left  ureter 
so  that  we  would  know  exactly  where  we  were.  We  then  cut  away  the  growth 
from  the  left  uterosacral  ligament  and  in  so  doing  cut  across  the  uterine 
artery  which  was  immediately  grasped  and  tied.  After  cutting  away  the 
growth  in  the  uterosacral  ligament,  we  brought  the  ends  of  the  ligament 
together  with  catgut,  made  a  purse-string  suture  over  the  area  and  drew 
things  together  leaving  the  site  of  the  nodule  perfectly  smooth.  We  then 
attached  the  fundus  to  the  anterior  abdominal  wall  with  one  plain  and  two 
chromicized  catgut  sutures  just  to  hold  the  uterus  up  in  position  for  a  month 
or  two  and  give  it  a  chance  to  diminish  in  size.  We  feared  there  might  be 
a  low  grade  infection  and  consequently  did  not  attempt  to  shorten  the  round 


OD 


Fig.  42  (Case  16). — Adenomyoma  of  the  rectovaginal  septum,  independent  adenomyoma 
of  the  sigmoid  almost  completely  blocking  the  lumen  of  the  bowel.  The  right  appendages 
have  been  removed,  the  right  broad  ligament  opened  up,  the  right  uterine  artery  ligated 
and  cut  and  the  ureter  dissected  out.  The  vagina  has  been  opened  and  the  adenomyomatous 
thickening  on  the  posterior  vaginal  wall  cut  away  from  the  vagina  and  left  attached  to  the 
rectum.  We  were  preparing  to  push  the  adenomyomatous  area  together  with  the  adjacent 
rectum  down  so  that  it  would  be  entirely  extraperitoneal  and  so  that  it  could  be  removed 
through  the  vagina  a  few  days  later.  At  this  moment,  however,  we  noted  the  puckered  area 
at  the  pelvic  brim.  This  bore  a  strong  resemblance  to  carcinoma,  but  no  metastases  could  be 
found,  so  we  came  to  the  conclusion  that  it  also  might  be  an  adenomyoma.  The  peritoneum 
of  the  sigmoid  was  then  severed  on  either  side  to  a  point  well  above  this  second  growth,  the 
entire  mass  was  pushed  down  to  the  pelvic  floor  and  the  peritoneum  so  drawn  over  it  that 
the  entire  area  was  practically  extraperitoneal.  The  abdomen  was  then  drained.  We  expected 
to  remove  the  entire  diseased  area  from  below  at  a  later  date.  The  patient,  however,  died 
of  infection.  At  necropsy  the  sigjnoid  growth  was  found,  as  indicated  by  the  picture,  to 
have  blocked  almost  completely  the  lumen  of  the  bowel.  It  was  a  typical  adenomyoma. 
This  accounted  for  the  fact  that  the  bowel  symptoms  were  so  marked  at  the  time  of  menstrual 
period.     For  the  histologic  picture  of  the  adenomyoma  of  the  sigmoid,  see  Figure  43. 


56 

ligaments.  We  removed  the  appendix  which  was  small,  but  the  meso-appendix 
showed  scars   of  old  trouble.     The  patient  was   discharged  June   12,    1919. 

September  22,  the  patient  looked  very  much  better.  The  uterus  was  in 
perfect  position  and  there  was  no  thickening  anywhere  in  the  pelvis. 

Examination  of  Specimen  (Gyn.  Path.  No.  25042). — It  was  noted  at  the 
time  of  operation  that  this  nodule  was  1.5  cm.  in  diameter.  On  section  it  is 
found  to  be  composed  of  nonstriped  muscle  and  fibrous  tissue,  and  embedded 
in  this  are  one  or  more  minute  discrete  myomas.  This  nodule  also  contains 
a  small  amount  of  adipose  tissue..  The  myoinatous  and  fibrous  tissue  tends 
to  spread  out  into  the  surrounding  fat.  Scattered  throughout  the  diffuse 
myoma  are  numerous  glands  (Fig.  40)  lined  with  one  layer  of  cylindric  epi- 
thelium. A  few  of  the  glands  occur  singly  and  lie  in  direct  contact  with  the 
muscle.  They  tend,  however,  to  occur  in  groups  and  are  surrounded  by  the 
characteristic  stroma.  Some  of  the  dilated  glands  contain  fresh  blood,  others 
debris  and  exfoliated  epithelial  cells  which  have  swollen,  become  spherical  and 
contain  yellowish  brown  pigment — the   remnant  of  old  menstrual  blood. 

This  is  a  well  defined  example  of  adenomyoma  of  the  uterosacral  ligament. 

ADENOMYOMA     OF     THE     SIGMOID     FLEXURE 

In  February,  1918,  Dr.  Thomas  E.  Neill  of  Washington,  D.  C, 
referred  to  me  a  patient,  aged  26,  complaining  of  most  excruciating 
menstrual  periods.  Since  April,  1917,  she  had  had  diarrhea  and 
with  the  beginning  of  each  period  she  would  have  definite  intestinal 
spasms  three  or  four  times  a  day.  These  would  last  two  days  and 
they  would  occur  just  at  the  time  the  patient  went  to  stool.  In  Septem- 
ber, she  was  put  on  a  milk  and  egg  diet.  Her  digestion  was  very 
much  upset  and  she  became  constipated.  During  the  last  three  or 
four  periods  she  had  had  pain  in  the  lower  bowel  commencing  about 
twenty-four  hours  before  the  period.  She  also  had  some  bleeding 
from  the  bowel  and  had  spasmodic  contraction  of  the  lower  bowel 
causing  nausea  and  retching. 

On  vaginal  examination,  I  found  a  hard,  slightly  nodular  and  raised 
area  in  the  vaginal  vault  directly  behind  the  cervix.  It  was  evident 
that  this  tumor  contained  several  small  cysts. 

At  operation  we  found,  in  addition  to  the  adenomyoma  of  the 
rectovaginal  septum,  an  independent  growth  in  the  sigmoid  near  the 
pelvic  brim.  This  presented  the  typical  appearance  of  carcinoma 
and  I  at  once  carried  my  hand  up  to  the  liver  to  see  if  there  were  any 
metastases.  None  being  felt,  I  thought  there  might  possibly  be 
some  relationship  between  the  adenomyoma  of  the  septum  and  that 
near  the  pelvic  brim.  As  the  patient's  condition  was  not  very  good, 
we  just  loosened  up  the  sigmoid  and  drew  it  down  extraperitoneally 
hoping  to  remove  it  at  a  second  operation  a  few  days  later.  Unfor- 
tunately, the  patient  developed  a  streptococcus  peritonitis  and  died. 
At  necropsy,  it  was  found  that  the  sigmoid  growth  was  a  typical 
adenomyoma  and  that  there  was  not  the  slightest  trace  of  cancer. 

This  case  is  of  such  interest  that  I  shall  report  it  in  detail. 


^-1 


»..  > 


V, 


"   ^  ' : 


^■^^.^^"\y 


adenomyomi  of  the^rect^vSf  s^ntum*^'^^^^  ^^^""  *°*""^  independent  of  a  coexisting 

the    sigmoid    growth    seen   fn    Figure    4^"     Thl    ''  f  Photomicrograph  of  a   section   taken   from 

the  underlying  muscular  walls^are  Satly  thickened'^^'so^ne";  d'tS^''^'^.''^  "°r^'-  ^'  ^ 
tissue  were  uterine  glands  surrounded  hvtL  m!o.-  , .Scattered  throughout  the  muscular 
brittle,  and  it  was  impossiWe  to  obtain  th^n  f  ^''.^'^t^'st'c  stroma.  The  tissue  was  unusually 
glands  and  stroma  in  the  muscle  sections.      Nevertheless,    at   c   we   can    recognize 


58 

Case  16  (Septum  Case  19). — Adenomyoma  of  the  rectovaginal  septum  with 
an  independent  adenomyoma  in  the  sigmoid  flexure  near  the  pelvic  brim,  clin- 
ically closely  simulating  a  carcinoma  of  the  sigmoid  and  markedly  narrowing 
the  lumen  of  the  bowel  (Figs.  41,  42  and  43). 

History  (Gyn.  No.  23764.  Gyn.  Path.  No.  23891).— Mrs.  G.  S.,  aged  26,  was 
referred  to  me  by  Dr.  Thomas  E.  Neill  of  Washington  on  Feb.  11,  1918.  Her 
menses  began  at  13.  When  14,  thej-  occurred  every  three  weeks.  She  was 
dilated  and  curetted  when  16,  and  was  gradually  having  more  comfortable 
periods.  The  flow  now  lasted  three  and  four  days,  formerly  it  lasted  from 
ten  daj-s  to  two  weeks.     She  had  had  severe  headaches,  but  these  had  been 


ti_  Adeno  myom^^l 
'///';//      in  lef-t  rectu^jj 


Pig.    44. — Adenomyoma    in    the    left    rectus    muscle, 
histologic  picture,  see  Figures  45  and  46. 


Dr.    Shallenberger"s    case.      For    the 


diminishing.  She  had  also  had  the  marked  intestinal  symptoms  referred  to 
above.  Her  last  period  was  two  weeks  before  I  saw  her.  She  gave  no  history 
of  any  previous  serious  illness. 

Examination. — On  pelvic  examination,  the  outlet  was  found  to  be  slightly 
relaxed,  the  cerv-ix  pointed  forward.  Just  behind  the  cervnx  was  a  globular, 
somewhat  lobulated  mass,  2  cm.  across,  2  cm.  from  above  downward.  It  com- 
menced directly  behind  the  cers'ix.  The  body  of  the  uterus  itself  was  normal 
in  size,  in  good  position,  and  no  thickening  could  be  made  out  on  either  side. 

On  admission  to  the  Johns  Hopkins  Hospital,  the  patient  had  hemoglobin 
of  78  per   cent.     She  was   in   rather   poor   condition   and   I   put  her   on   forced 


59 


nourishment  for  two  weeks  before  attempting  any  abdominal  procedure.  Dr. 
M.  Bloomfield  examined  the  lungs  and  found  evidence  of  old  tuberculosis  in 
the  left  apex. 

Operation  and  Result.— April  4.  1918,  we  operated.  First  of  all  we  grasped 
the  posterior  lip  of  the  cervix  and  drew  it  forward,  put  a  retractor  in  poste- 
riorly and  then  one  on  the  right.  We  were  then  enabled  to  see  an  oval  area. 
about  2.5  by  2  cm.,  directly  behind  the  cervix  (Fig.  41).  This  was  slightly 
nodular  and  in  the  center  of  some  of  the  nodules  was  a  shiny  condition  indi- 
cating that  at  such  points  a  small  cyst  existed.  One  or  two  of  these  were 
bluish  black  in   color,  and  there  was   absolutely  no   doubt  that  we  were   deal- 


'■    ^ 


iS'i' 


irU 


^.  ^'1  ^. 


j<'  „^    ^- 


:^>*-  <-^ 


TT-  ^'^"  //.— Adenomyoma  in  the  left  rectus  muscle.  For  the  location  of  the  tumor,  see 
^i'^^K  :  :  ^  nodule  consisted  of  nonstriped  muscle  and  fibrous  tissue,  and  scattered 
throughout  it  were  areas  of  typical  uterine  mucosa. 

ing  with  an  adenomyoma  of  the  rectovaginal  septum.  The  edge  of  the  growth 
was  slightly  raised,  probably  1  mm.  from  the  surface  of  the  vaginal  mucosa. 
We  made  an  incision  posterior  to  the  cervix,  separated  the  cervix  from  the 
vagina  and  then  on  the  right  side  we  cut  the  vaginal  mucosa  near  the  growth 
and  loosened  it  up  as  much  as  possible.  We  then  packed  the  vagina  tightly 
with  gauze  and  made  a  median  abdominal  incision.  The  right  tube  and  ovary 
were  removed  in  order  that  we  might  get  into  the  right  broad  ligament  satis- 
factorily.    We  dissected   out  the  right  ureter,   cut  the  right  uterine  artery  and 


60 

then  separated  the  bladder  peritoneum  from  the  anterior  surface  of  the  uterus 
to  a  point  slightly  beyond  the  median  line.  We  gradually  loosened  up  the 
growth  in  the  right  broad  ligament  from  the  peritoneum  on  the  right  side 
of  the  rectum  for  a  short  distance  and  then  cut  the  vaginal  mucosa  around 
it  so  that  we  finally  had  the  uterus  shoved  over  to  the  left  side  and  a  button 
of  the  vaginal  mucosa  containing  the  growth  still  left  attached  to  the  rectum 
(Fig.  42).  We  had  partly  closed  the  vagina,  after  pulling  the  rectal  growth 
down  into  it,  when  we  noticed  a  constriction  about  six  inches  above  where  the 
rectal  growth  had  been.  Whether  the  growth  in  the  upper  part  of  the  sigmoid 
was  carcinoma  or  not  it  was  impossible  to  tell.  After  examining  the  pelvic 
glands  and  also  the  liver  and  finding  no  evidence  of  metastases  nor  any 
enlarged  lymph  glands,  I  came  to  the  conclusion  that  this  might  be  another 
adenomyoma,  although  I  had  never  seen  one  in  such  a  position.  We  cut 
the  peritoneum  on  either  side  of  the   sigmoid  up  as  high   as  the  pelvic  brim, 


Fig.    46. — Adenomyoma    in    the    left    rectus    muscle.      For    the    location    of   the    tumor,    see 
Figure  44.     Scattered  throughout  the  myoma  are  areas  of  normal  uterine  mucosa. 


loosened  up  the  rectum  as  far  as  possible  without  interfering  with  its  blood 
supply  and  then  pushed  the  sigmoid  well  down  into  the  pelvis  and  drew  the 
pelvic  peritoneum  over  to  the  pelvic  brim  so  we  could  wall  off  this  area  of 
the  sigmoid.  When  we  had  finished  the  operation,  the  sigmoid  had  been  pushed 
down  extra,peritoneally.  A  drain  was  left  in  the  lower  angle  of  the  incision 
down  behind  the  uterus.    The  patient  was  in  fair  condition. 

We  hoped  at  a  later  date  to  draw  the  bowel  out  through  the  vagina  and 
perform  an  end  to  end  anastomosis  if  possible.  To  have  done  anything  more 
at  the  time  would  undoubtedly  have  caused  the  death  of  the  patient. 

For  the  first  twenty-four  hours  the  patient  did  fairly  well,  but  the  next 
day  she  commenced  to  vomit  a  small  amount  of  greenish  fluid.  There  was  a 
good   deal   of   abdominal    distention. 


61 


On  March  7,  the  patient  was  delirious,  vomited  frequently,  and  was  very- 
restless,  tossing  from  side  to  side.  On  March  8,  at  3 :  30  p.  m.,  I  performed 
an  enterostomy,  thinking  there  might  be  intestinal  obstruction.  The  bowel 
was  relatively  smooth,  but  there  was  some  infection  low  down  in  the  pelvis. 
The  patient  died  at  9  p.  m. 

Necropsy  Findings. — A  definite  peritonitis  existed.  The  rectovaginal  growth 
consisted  of  typical  adenomyomatous  tissue,  and  the  tumor  that  projected  in 
the  sigmoid  near  the  pelvic  brim  and  markedly  constricted  the  lumen  of  the 
bowel  also  consisted  of  characteristic  adenomyomatous  tissue    (Fig.  43). 

Cuthbert  Lockyer,^  in  his  excellent  book  on  "Fibroids  and  Allied 
Tumors,"  gives  us  the  best  resume  of  the  literature  on  adenomyoma. 
In  it,  he  refers  at  length  to  an  interesting  case  reported  by  Robert 
Meyer.*^  On  referring  to  Meyer's  article  I  found  that  the  patient 
was  45  years  of  age,  and  that  Professor  Mackenrodt  had  performed 
a  resection  in  1907  as  the  patient  had  signs  of  stenosis  of  the  bowel. 


Fig.  47  (Case  17). — Adenomyoma  of  the  umbilicus.  Dr.  Guthrie's  case.  Projecting 
from  the  umlailical  depression  is  a  small  tumor.  This  was  1.5  cm.  long.  On  section  it  was 
seen  to  contain  several  small  cysts.  Some  of  them  were  yellowish  brown  color.  For  the 
low  power  picture,   see   Figure   48.     For  the  higher   magnification,    Figure   49. 

The  specimen  consisted  of  a  segment  of  the  bowel  8  cm.  in  length. 
The  bowel  lumen  over  an  area  1.5  cm.  long  was  markedly  narrowed, 
there  being  just  a  slitlike  opening.  The  mesocolon  at  this  point  and 
also  the  overlying  bowel  mucosa  were  markedly  thickened.  In  the 
mesocolon   between   the   layer  of  fat   and  the  muscular   wall   of   the 


5.  Lockyer,  Cuthbert :  Fibroids  and  Allied  Tumors,  New  York,  the  Mac- 
millan  Company,  1917. 

6.  Meyer,  Robert :  Ueber  entziindliche  heterotope  Epithelwucherungen  im 
weiblichen  Genitalgebiete  und  iiber  eine  bis  in  die  Wurzel  des  Mesocolon 
ausgedehnte  benigne  Wucherung  des  Darmepithels,  Virchows  Arch.  f.  path 
Anat.  195  :487,  1919. 


62 

sigmoid  was  an  irregular  fanlike  connective-tissue  tumor,  diffuse  in 
character,  and  strongly  suggesting  an  adenomyoma.  The  tumor  pro- 
jected into  the  bowel  and  produced  a  folding  of  the  overlying  mucous 
membrane. 

On  histologic  examination,  the  mucous  membrane  of  the  bowel 
over  the  tumor  folds  was  found  to  have  practically  disappeared,  the 
surface  consisting  of  granulation  tissue.  The  tumor  consisted  of 
adenomyomatous  tissue. 

Meyer's  pictures  leave  no  doubt  that  he  was  dealing  with  an 
adenomyoma  of  the  sigmoid,  an  adenomyoma  of  a  type  resembling 
in  nearly  every  particular  that  found  in  the  uterus.  This  is  the  first 
case  of  this  character  that  I  have  found  any  record  of.  It  was 
clearly  described  in  Cuthbert  Lockyer's  recent  publication. 

On  Oct.  24,  1919,  I  received  a  most  interesting  letter  from  my 
friend,  Dr.  G.  Brown  Miller  of  Washington,  D.  C,  the  contents  of 
which  have  a  definite  bearing  on  the  association  of  adenomyoma  of 
the  rectovaginal  septum  with  secondary  adenomyoma  in  the  sigmoid. 

Mrs.  P.,  aged  36,  with  no  children,  came  to  see  Dr.  Miller  on  June  26,  1919, 
complaining  of  profuse,  prolonged  and  painful  menstruation,  pain  in  the  pelvis 
and  pain  on  defecation.  She  had  recently  lost  a  good  deal  of  weight  but  was 
still  well  nourished  although  somewhat  anemic. 

Vaginal  examination  showed  the  cervix  to  be  large  and  liard,  and  a  small 
polypoid  tumor  was  protruding  from  the  os.  In  the  upper  part  of  the  poste- 
rior vaginal  vault  was  an  irregular,  hard,  nodular  tumor  mass  the  size  of  a 
walnut.  It  was  intimately  connected  with  the  cervix,  rectum  and  broad  liga- 
ment. The  rectal  mucosa  over  the  tumor  was  intact  but  was  intimately  adher- 
ent to  the  mass.  The  uterus  was  retroverted  and  moderately  enlarged.  A 
diagnosis  of  adenomyoma  of  the  rectovaginal  septum  was  made. 

The  patient  was  sent  to  the  Columbia  Hospital  and  was  operated  on  a  few 
days  later.  I  was  assisted  by  Dr.  Neill.  When  more  carefully  examined 
immediately  before  operation  the  nodules  in  the  vaginal  vault  were  seen  to 
contain  small  bluish  cysts  the  size  of  a  pin. 

On  opening  the  abdomen  the  first  thing  which  attracted  one's  attention 
was  a  mass  the  size  of  a  large  lemon  which  was  situated  in  the  upper  part  of 
the  rectum  or  lower  sigmoid.  This  seemed  to  encircle  the  lumen  of  the  bowel. 
The  patient  gave  no  history  of  hemorrhage  from  the  bowel  or  of  bloody  stools. 
A  total  hysterectomy  was  performed.  It  was  a  difficult  operation  on  account 
of  the  fixation  of  the  uterus.  In  attempting  to  separate  the  growth  from  the 
rectum,  an  opening  was  made  in  the  bowel  after  which  the  whole  involve- 
ment of  the  rectum  by  the  tumor  was  cut  away  and  the  rectum  was   sutured. 

No  attempt  was  made  to  resect  the  growth  in  the  sigmoid.  The  patient 
left  the  table  in  bad  condition.  Her  pulse  was  rapid  and  she  was  much  shocked. 
She  improved  and  the  next  day  was  much  better.  I  left  town  the  following  day 
and  was  hopeful  that  she  might  recover,  but  learned  from  Dr.  Neill  that 
about  eight  or  nine  days  after  the  operation  she  apparently  developed  peri- 
tonitis and  soon  died. 


63 

Mahle  and  MacCarty  "  report  a  very  interesting  case  of  adeno- 
myoma  of  the  sigmoid  observed  in  the  Mayo  Clinic : 

Case  4. — The  adenomyoma  of  the  sigmoid  occurred  in  a  patient,  aged  31, 
who  had  been  married  eleven  years  and  pregnant  once.  She  had  had  an 
appendectomy,  salpingectomy,  and  partial  oophorectomy  performed  elsewhere. 
At  that  time  she  was  told  that  she  had  a  tumor  of  the  lower  bowel  which  would 


Fig.  48  (Case  17). — Adenomyoma  of  the  umbilicus.  This  is  a  low  power  picture  of  the 
umbilical  tumor  seen  in  Figure  47.  The  surface  is  covered  with  normal  skin.  Scattered 
everywhere  throughout  the  tumor  are  glands,  many  of  them  cystic,  and  not  a  few  surrounded 
by  a  definite   stroma  that   stains   rather   deeply.     For   the   higher  power,    see   Figure   49. 

become  a  cancer.  She  presented  herself  at  the  clinic  because  of  this  tumor. 
Roentgen  ray  of  the  colon,  and  a  proctosigmoidoscopic  examination  proved 
negative. 


7.  Mahle,  A.   E.,   and   MacCarty,  W.   C. :    Ectopic   Adenomyoma   of  Uterine 
Type  (A  Report  of  Ten  Cases),  J.  Lab.  &  Clin.  M.  5:221  (Jan.)  1920. 


64 

At  operation  a  tumor  mass  was  found  encircling  the  sigmoid,  involving  a 
segment  of  the  bowel  4  cm.  in  length.  The  sigmoid  and  the  bladder  were 
adherent  to  a  mass  around  the  uterus.  Twelve  centimeters  of  sigmoid  were 
removed  as  well  as  "tarry"  cysts  of  both  ovaries. 

Histologic  examination  of  the  sigmoid  growth  showed  the  char- 
acteristic picture  of  adenomyoma.  Mahle  and  MacCarty  refer  to 
an  adenomyoma  of  the  sigmoid  observed  by  Leitch. 

Further  studies  will  undoubtedly  bring  to  light  other  cases  and 
it  is  highly  probable  that  some  cases  heretofore  considered  to  have 
been  cancer  were  as  a  matter  of   fact  adenomyomas. 

ADENOMYOMA     OF     THE     RECTUS     MUSCLE 

These  growths  are  exceedingly  rare.  Dr.  William  F.  Shallenberger 
of  Atlanta  kindly  sent  me  a  resume  of  the  history  of  his  case  on 
Nov.  8,  1919. 

History. — Mrs.  C.  E.  D.,  aged  34,  had  been  married  more  than  ten  years. 
Nine  and  a  half  years  ago  she  had  an  abortion.  Curettage  was  performed  for 
retained  membranes  and  the  dilator  passed  through  the  retroflexed  uterus 
at  the  cervical  uterine  junction.  The  body  of  the  uterus  was  torn  half  loose 
from  the  cervix  before  the  accident  was  discovered.  The  patient  evidenced 
considerable  shock,  was  rushed  to  the  hospital,  the  abdomen  was  opened 
and  the  damage  repaired. 

Dr.  Shallenberger  also  learned  that  the  patient  had  a  second  pregnancy 
eight  years  ago.  She  went  to  term,  had  a  normal  labor  but  following  labor 
a  hematoma  developed  in  the  left  broad  ligament  and  vaginal  wall.  This  had 
to  be  opened  through  the  vagina.  The  patient's  health  has  been  very  good 
since  the  last  labor,  aside  from  a  slight  attack  of  cystitis  three  years  ago  and 
a  streptococcus  infection  of  the  foot  six  months  ago. 

The  menstrual  history  was  normal  in  every  way. 

Present  Illness. — Three  days  ago  the  patient  noticed  a  little  soreness  in  the 
lower  abdomen  just  to  the  left  of  the  lower  angle  of  the  abdominal  scar 
(Fig.  44).  On  feeling  this  area  she  noticed  a  small  tender  swelling.  She 
thought  that  a  hernia  was  developing. 

On  inspection  there  was  a  slight  fulness  just  to  the  left  of  the  midline  and 
slightly  above  the  symphysis.  On  palpitation  a  small  firm  nodule  could  be  felt 
apparently  in  the  belly  of  the  rectus  muscle.  This  did  not  seem  to  be  asso- 
ciated with  the  scar  of  the  incision  and  there  was  no  impulse  on  coughing  or 
straining,  and  the  nodule  did  not  increase  in  size  when  the  patient  stood.  Dr. 
Shallenberger  thought  he  was  dealing  with  a  hernia  or  with  a  dermoid  tumor 
of  the  rectus  muscle. 

Treatment. — The  patient  was  put  to  bed  and  an  ice  cap  was  placed  over 
the  lower  abdomen.  The  pain  and  soreness  were  not  relieved  and  the  nodule 
apparently  increased  somewhat  in  size  during  the  next  four  days.  Dr.  Shallen- 
berger then  decided  to  remove  the  nodule.  The  entire  lower  end  of  the  left 
rectus  was  removed.  The  tumor  was  about  2.5  to  3  cm.  in  length,  about 
1.5  cm.  in  breadth  and  1.5  cm.  thick.     It  had  no  definite  ca,psule. 


65 

On  cutting  into  the  tumor  Dr.  Shallenberger  found  that  it  presented  a  dark 
grayish  mottled  appearance  and  that  it  was  firm  and  fibrous  in  character. 

The  operation  was  performed  eleven  months  ago  and  the  patient  made  an 
uneventful  recovery. 

Sections  from  this  growth  sent  to  me  by  Dr.  Shallenberger  con- 
sist of  nonstriped  muscle.  Scattered  throughout  this  are  areas  of 
characteristic  uterine  stroma  containing  normal  appearing  uterine 
glands  (Figs.  45  and  46).  The  cavities  of  some  of  the  glands  con- 
tain blood  and  in  the  stroma  at  some  points  is  brown  pigment. 

The  tumor  in  the  case  reported  by  Dr.  Shallenberger  is  without 
doubt  an  adenomyoma  occurring  in  the  left  rectus  muscle.  It  is  the 
first  one  of  this  character  that  I  have  ever  heard  of.  From  its  location 
it  could  not  for  a  moment  be  confused  with  adenomyoma  of  the  round 
ligament  which,  although  it  presents  exactly  the  same  histologic  picture, 
is  usually  situated  at  or  near  the  external  or  the  internal  ring. 

Mahle  and  MacCarty  '  record  two  cases  of  adenomyoma  of  the 
abdominal  wall : 

Case  2. — This  patient,  aged  30,  complained  of  a  tender  lump,  of  two  years' 
duration,  in  the  lower  abdominal  wall,  under  a  previous  laparotomy  scar.  The 
lump  was  painful  at  the  time  of  menstruation. 

On  examination  a  palpable  mass,  3  cm.  in  diameter,  was  found  beneath 
the  lower  end  of  a  median  laparotomy  scar;  this  was  hard,  nodular  and 
painful  to  touch.  It  was  apparently  not  attached  to  the  uterus,  and  clinically, 
was  thought  to  be  a  fibrous  tumor  in  a  previous  laparotomy  wound. 

At  operation,  the  mass  was  removed ;  it  extended  through  the  abdominal 
muscles,  and  was  attached  to  the  left  tube  about  4  cm.  from  the  uterine  horn. 

Case  3. — This  patient,  aged  46,  had  had  a  ventral  suspension  performed 
several  years  before  and  had  been  pregnant  nine  times,  the  last  pregnancy 
occurring  ten  years  before.  She  complained  of  lumps  in  the  abdominal  wall, 
which  she  had  noticed  for  the  last  year.  These  lumps  had  not  grown  noticeably 
larger  but  had  always  been  painful  following  menstruation. 

On  examination,  a  mass  was  found  in  the  suprapubic  region,  apparently 
in  the  abdominal  wall,  movable  with  it,  and  possibly  connected  with  the  fundus 
of  the  uterus.  Clinically,  it  was  thought  to'  be  a  fibrous  growth,  attached  to 
the  abdominal  wall  on  a  previously  ventrosuspended  uterus. 

At  operation,  the  fundus  of  the  uterus  was  found  attached  to  the  abdominal 
wall.  The  tumor,  8  cm.  in  diameter,  was  situated  to  the  right  of  the  midline, 
and  extended  down  to  the  right  side  of  the  uterus.  It  was  solid,  with  glandular, 
cystic  areas  filled  with  black  pigment.  Because  of  its  extension  into  the  retro- 
peritoneal tissue,  and  apparent  inoperability,  only  a  piece  of  tissue  6  cm.  in 
diameter,  was  excised  for  diagnosis. 

ADENOMYOMA     OF     THE     UMBILICUS 

From  time  to  time  a  small  thickening  has  been  noted  at  the 
umbilicus  in  women  during  the  child-bearing  period.  In  some  of  these 
cases,  the  tumor  has   increased   in   size   perceptibly  at   the   menstrual 


66 


period,  and  in  a  few  there  has  been  a  discharge  of  blood  from  the 
umbihcus  at  the  period.  (Jccasionally,  small  bluish  black  cysts  have 
been  noted  in  the  tumor. 

Adenomyomas  of  the  umbilicus  are  always  small.  On  histologic 
examination,  they  are  found  covered  over  with  normal  skin.  They 
consist  of  fibrous  tissue  and  nonstriped  muscle,  and  scattered  through- 


Fig  49  (Case  17).— Adenomyoraa  of  the  umbilicus.  This  section  is  from  the  umbilical 
nodule  seen  in  Figure  47.  In  the  center  of  the  field  is  typical  uterine  mucosa.  Some  of  the 
glands  are  dilated. 

out  this  are  islands  of  typical  uterine  mucosa.     When  the  history  is 
characteristic,  the  diagnosis  can  be  made  with  ease. 

It  is  not  necessary  for  me  to  discuss  this  subject  in  detail,  as  I 
have  devoted  an  entire  chapter  to  adenomyomas  of  this  region  in  my 
book  on  the  umbilicus. 


G7 

Removal   of  the  umbilicus  is  all  that  is  essential  in  these  cases. 
I  shall  report  briefly  on  the  specimens  of  two  cases  of  adenomyoma 
that    have    recently    been    sent    me    for    examination. 

Case  17. — Adenomyoma  of  the  umbilicus  (Figs.  47,  48  and  49). 

History. — The  specimen  was  sent  me  by  Dr.  Donald  Guthrie  of  the  Robert 
Packer  Hospital,  Sayre,  Pa.,  in  March,  1919.     Dr.  Guthrie  says  : 

"The  patient  is  46  years  of  age.  She  has  had  two  children — the  youngest 
16  years  of  age.  Menstruation  has  been  regular.  The  patient  has  experienced 
severe  pain  around  the  umbilicus  at  the  menstrual  period.  She  has  noticed 
this  for  two  years,  and  at  this  time  discovered  an  enlargement  of  the  umbilicus. 
She  never  has  had  any  discharge  from  it.     At  the  menstrual  period  when  the 


Fig.  50  (Case  18). — Adenomyoma  of  the  umbilicus.  The  specimen  was  sent  me  by  Dr. 
Lester  Adams.  The  overlying  skin  is  normal.  The  tumor  is  sharply  circumscribed,  has  a 
whorled  appearance,  and  has  scattered  throughout  it  cystic  spaces  and  dark  areas,  some  of 
them  with  glands   in  their  centers.     For  the   histologic   picture,    see   Figure   51. 


4 


umbilicus  was  paining  her,  the  patient  experienced  some  inflammatory  symp- 
toms of  the  bladder.  She  has  become  very  nervous  and  fearful  that  she  has 
a  cancer." 

Dr.  Guthrie  sent  me  the  specimen  shortly  after  its  removal. 

Examination  of  Specimen  (Gyn.  Path.  No.  24792). — The  specimen  consists 
of  the  umbilicus  and  of  the  adjoining  skin.  The  umbilical  depression  is  filled 
with  a  small  growth  1.5  cm.  in  diameter  (Fig.  47).  This  on  section  appears 
firm,  but  scattered  throughout  it  are  a  few  cystic  spaces,  some  of  them  yel- 
lowish brown — cancer  was  suspected  clinically. 


68 


¥'*'^l^ 


Fig.  51  (Case  18).— Adenomyoma  of  the  umbilicus.  The  overlying  skin  is  normal.  _  Some 
of  the  glands  are  partially  surrounded  by  a  definite  stroma,  others  he  m  contact  with  the 
myomatous  tissue.      For  the   low   power  picture,   see   Figure   SO. 


69 

Histologic  Ejicamination. — The  low-power  picture  is  well  shown  in  Figure  48. 
The  free  surface  is  covered  with  normal  squamous  epithelium'.  The  greater 
part  of  the  tumor  is  made  up  of  colonies  of  glands  embedded  in  a  definite 
stroma.  Quite  a  number  of  the  glands  are  dilated  and  filled  with  grayish  or 
brownish   material.     Here   and   there   is    a   perfectly   definite   miniature   uterine 

cavity. 

With  a  higher  power  it  is  seen  that  the  matrix  of  the  tumor  is  made  up  of 
connective  tissue  with  bundles  of  nonstriped  muscle  scattered  liberally  through- 
out it.  Everywhere  throughout  the  tumor  are  glands.  Some  are  minute  and 
lie  in  direct  contact  with  the  muscle;  others  are  larger  and  embedded  m  a 
rarefied  stroma.  Many  occur  in  groups  and  are  embedded  in  a  stroma  iden- 
tical with  that  of  the  uterine  mucosa  (Fig.  49).  This  mucosa  is  in  some  places 
so  arranged  that  miniature  uterine  cavities  occur.  Some  of  the  gland  cavities 
are  filled  with  blood,  and  here  and  there  throughout  the  stroma  of  the  growth 
are  areas  of  yellowish  brown  pigment— the  remnants  of  old  menstrual  blood. 
One  could  not  wish  for  a  more  beautiful  example  of  an  adenomyoma  of  the 
umbilicus. 

Case  18.— Adenomyoma  of  the  umbilicus  (Figs.  50  and  51). 

History.— Ih'i?,  specimen  was  sent  me  liy  Dr.  Lester  Adams  of  the  Eastern 
Maine  General  Hospital.  Bangor,  Me.  M.  G.,  aged  il .  was  under  the  care 
of  Dr.  Hunt.  An  umbilical  growth  was  removed  on  Nov.  8,  1916.  About  a 
year  before  the  operation  she  had  noticed  pain  at  the  umbilicus  at  the  men- 
strual period,  but  at  no  other  time.  There  was  some  increase  in  size  of  the 
umbilicus  at  the  periods.  Recently  the  pain  and  tenderness  in  the  uml)ilical 
region  had  increased  markedly. 

Examination  of  Specimen  (Gyn.  Path.  No.  22657).— The  specimen  consists 
of  a  growth,  1.3  cm.  in  diameter,  occupying  the  umbilical  region.  On  section 
it  is  very  dense,  but  at  two  points  are  small  cysts,  the  larger  being  2  mm.  in 
diameter. 

On  histologic  examination,  the  overlying  skin  is  found  to  be  normal  (Fig. 
50).  The  tumor  growth  is  made  up  of  nonstriped  muscle  and  fibrous  tissue. 
Scattered  throughout  the  tumor  are  large  numbers  of  glands,  some  occur  singly 
and  lie  in  direct  contact  with  the  muscle.  The  majority,  however,  occur  m 
groups  and  are  separated  from  the  muscle  by  a  definite  stroma  (Fig.  51). 
This  at  some  points  is  rarefied,  but  in  other  places  is  identical  with  that  of 
the  uterine  mucosa.  In  at  least  one  place  is  a  miniature  uterine  cavity.  Some 
of  the  glands  are  filled  with  blood,  others  with  exfoliated  epithelium  and 
debris.  In  the  outlyng  portions  of  the  tumor  are  colonies  of  sweat  glands. 
This  is  another  example  of  adenomyoma  of  the  umbilicus. 

SUMMARY 

From  the  foregoing,  we  have  seen  that  adenomyomas,  consisting 
of  a  matrix  of  nonstriped  muscle  and  fibrous  tissue  with  typical 
uterine  mucosa  scattered  throughout,  are  to  be  found  in  the  uterus, 
rectovaginal  septum,  tubes,  round  ligaments,  utero-ovarian  ligaments, 
uterosacral  ligaments,  sigmoid  flexure,  rectus  muscle  and  umbilicus, 
and  that  we  occasionally  find  large  quantities  of  normal  uterine  mucosa 
in  the  ovary.  Adenomyomas  form  one  of  the  most  interesting  groups 
of  muscle  that  we  have  to  deal  with  in  the  female  pelvis. 


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